1246

The Ways of Coping

Checklist (WCC)
Validation in French-
speaking Cancer Patients
FLORENCE COUSSON- GLI E
Laboratoire de Psychologie Sant et Qualit de vie EA 4139,
IFR Sant publique, Universit Bordeaux 2, France
OLI VI ER COSNEFROY
Laboratoire de Psychologie Sant et Qualit de vie EA 4139,
IFR Sant publique, Universit Bordeaux 2, France
VRONI QUE CHRI STOPHE
URECA EA 1059, Equipe Famille, Sant & Emotion,
Universit de Lille 3, France, and Centre Oscar Lambret,
Lille, France
CARI NE SEGRESTAN- CROUZET
Laboratoire de Psychologie Sant et Qualit de vie EA 4139,
IFR Sant publique, Universit Bordeaux 2, Bordeaux, France
I SABELLE MERCKAERT
Psychosomatic and Psycho-Oncology Research Unit,
Universit Libre de Bruxelles, Belgium
EMMANUELLE FOURNI ER
URECA EA 1059, Equipe Famille, Sant & Emotion,
Universit de Lille 3, France, and Centre Oscar Lambret, Lille,
France
YVES LI BERT
Psychosomatic and Psycho-Oncology Research Unit,
Universit Libre de Bruxelles, and Insitut Jules Bordet,
Bruxelles, Belgium
ANA S LAFAYE
Laboratoire de Psychologie Sant et Qualit de vie EA 4139,
IFR Sant publique, Universit Bordeaux 2, France
DARI US RAZAVI
Psychosomatic and Psycho-Oncology Research Unit,
Universit Libre de Bruxelles, Belgium
Abstract
We explore the psychometric
properties of the French version of the
Ways of Coping Checklist Revised
(WCC-R) for a cancer patient sample.
The WCC-R was completed by 622
patients and 464 completed the State-
Trait Anxiety Inventory (STAI). A
confirmatory factor analysis (CFA) on
the original factor structure did not fit
the data. The sample was randomly
divided into two subsamples.
Exploratory factor analysis was
conducted on one subsample and
revealed three factors: Seeking social
support, Problem focused-coping
and Self-blame and avoidance,
including 21 items. A CFA confirmed
this structure in the second subgroup.
These scales correlated with the
anxiety scores.
Journal of Health Psychology
Copyright 2010 SAGE Publications
Los Angeles, London, New Delhi,
Singapore and Washington DC
www.sagepublications.com
Vol 15(8) 12461256
DOI: 10.1177/1359105310364438
ACKNOWLEDGEMENTS. This study was partly supported by the Service
Publique Fdral Sant Publique, Scurit de la Chaine alimentaire of
Belgium under the Appel doffre-2002-16 and by the CAM (Training and
Research Group) of Belgium and by the Institut National du Cancer (INCa)
of France.
COMPETI NG I NTERESTS: None declared.
ADDRESS. Correspondence should be directed to:
FLORENCE COUSSON- GLI E, PhD, Health Psychology and Quality of
Life Laboratory, Universit de Bordeaux 2, 3 place de la Victoire, 33076,
Bordeaux, France.
Keywords
I cancer
I confirmatory factor analysis
I coping
I measurement
COUSSON-GLIE ET AL: THE WAYS OF COPING CHECKLIST (WCC)
1247
When confronted with stressful life events,
individuals normally resort to a wide range of
coping strategies to modify the impact of stress.
Research on coping over the past 30 years has been
dominated by contextual models that emphasize
coping by a person situated in a particular stressful
encounter (Lazarus & Folkman, 1984a, 1984b) or
stressful social condition (e.g. Pearlin, Lieberman,
Menaghan, & Mullin, 1981; Pearlin & Schooler,
1978). In the Lazarus transactional model of stress,
each individual faced with a stressful situation sets
up specific adjustment strategies called coping,
including a meaningful pattern of cognitive,
behavioral, emotional and somatic responses. The
first generation coping theoreticians and
researchers proposed a taxonomy taking account
two separate types of processes, leading to the
distinction between problem-focused (i.e. strategies
directed at solving the impact of the stressful event)
and emotion-focused (i.e. efforts directed at affect
regulation) coping (Lazarus & Folkman, 1984b).
More recent research on conceptualizing coping
included the addition of a third strategy (i.e. seeking
social support) (Greenglass, 1993; Litman, 2006),
as well other two-dimensional configurations (i.e.
approach vs. avoidance) (Holahan & Moos, 1987;
Krohne, 1996; Moos & Holahan, 2003).
The measurement of coping received a boost in the
1980s by the development of the Ways of Coping
Checklist (WCC) (Folkman & Lazarus, 1980). The
WCC is a well-known measure of coping responses
derived from Lazarus transactional model of stress.
The items were derived from a problem-focused
subscale (24 items) and from an emotion-focused
subscale (40 items). Aldwin Folkman, Shaefer,
Coyne and Lazarus (1980) administered the WCC to
100 subjects and found seven interpretable factors
(one problem-focused coping and six different kinds
of emotion-focused coping). The subject-items ratio
raised the question about the quality of the factor
structure (Parker & Endler, 1992). The WCC was
validated by Vitaliano and colleagues (Vitaliano,
Russo, Carr, Maiuro, & Becker, 1985) on 425
medical students. Five subscales containing 42 items
were identified: problem-focused; seeking social
support; blamed self; wishful thinking; and
avoidance. Cousson et al. (1996) administered the
French version of the WCC validated by Vitaliano et
al. (1985) to 468 adult subjects and found a three-
factor solution: problem-focused; emotion-focused;
and social-support seeking. The revised instrument
contained a 27-item French version of the WCC with
good internal consistency, test-retest reliability, and
construct and criterion validities (WCC-R; Cousson,
Bruchon-Schweitzer, Quintard, & Nuissier, 1996).
When investigating coping strategies with cancer,
some authors have typically employed measures of
coping with life stresses in general, such as the
WCC or the COPE,
1
whereas others are more
disease-specific, such as the Mental Adjustment to
Cancer scale (MAC).
2
Dunkel-Schetter, Feinstein,
Taylor, & Falke (1992) identified five coping
strategies in analyzing the factor structure of the
WCC (Lazarus & Folkman, 1984a) administered to
603 USA cancer patients: seeking or using social
support; focusing on the positive; distancing;
cognitive escape-avoidance; and behavioral escape-
avoidance. The authors did not report the percent of
total variance explained by the five factors. We
decided to use the WCC-R (Cousson et al., 1996) as
the starting point in our psychometric analysis. First,
given the importance of measuring coping with
cancer and the relative absence of coping
instruments in French-speaking subjects (only the
MAC scale validated in French cancer patients),
additional instruments are needed. Second, this
instrument is a reliable operationalization of the
concept of coping as defined by Lazarus and
Folkman, and we wanted to know both the clinical
generalizability and construct validity of the WCC
scales in French cancer patients. Third, the revised
WCC scale containing 27 items corresponded to the
three principal coping strategies identified in the
French population (Cousson et al., 1996).
The aim of the present study was to explore the
psychometric properties of the French version of the
WCC-R (Cousson et al., 1996) for a cancer patient
sample. We decided to develop a specific cancer
version of a coping questionnaire for three main
reasons: (1) the inappropriateness of some of the
WCC-R items in our sample; (2) cultural differences
interfering in the understanding of the questions by the
subjects; and (3) diversity in the factor structure due to
the specific stressful situation. Lazarus and Folkman
(1984b) indicated that a subject will cope differently
as a function of the stressful situation, in particular if
the situation is non-controllable. Cancer includes a
wide range of situations with which to cope such as
painful or secondary effects of treatment, fear of
cancer recurrence and changes in social relationships.
We also examined the construct validity and factor
structure of the original scales and the associations
with anxiety (trait and state). Previous work has
indicated that emotion-focused coping strategies are
JOURNAL OF HEALTH PSYCHOLOGY 15(8)
1248
consistently associated with greater anxiety (Ben-Zur,
1999; Cousson-Glie, 2000; David, Montgomery, &
Bovbjerg, 2006; Schnoll, Harlow, Stolbach, & Brandt,
1998). However, as pointed out by Stanton et al.
(2000), many WCC items are often confounded with
expression of emotion. Therefore, we hypothesized
that high emotion-focused coping would be linked
with high state anxiety. Since dispositional anxiety is
conceptualized as vulnerability to stress response, we
hypothesized that presence of trait-anxiety is
associated with high emotion-focused coping.
Materials and methods
Sample
To achieve a heterogeneous sample of French-
speaking cancer patients, the sample of this
multicenter, descriptive, cross-sectional study
consisted of a total of 622 patients attending two
French hospitals (n = 217) and eight Belgian
hospitals (n = 405). To fulfill the inclusion criteria,
patients had to be in- or out-patients; to be at least 18
years old; to be aware of their cancer diagnosis; to
be fit enough to complete the questionnaire
according to their physician; to be French speaking
and to be free of any cognitive dysfunction. Patients
gave their written informed consent as regards
participation in the study. They were excluded when
they had just been diagnosed or when they were
hospitalized in palliative care units. A total of 765
patients were approached and 143 patients refused
to participate (24%). Six hundred and twenty two of
the patients completed a whole questionnaire
including the WCC and a total of 464 patients
(French and Belgian) also completed the State-Trait
Anxiety Inventory (STAI). Sociodemographic
characteristics of the sample are shown in Table 1.
The sample was randomly divided into two
subsamples of 312 and 310 participants. The first
subsample was considered as the calibration sample
and the second as the replication sample. Participants
mean age in the first subsample was 58.99
(SD = 13.10), and the mean age in the second was
57.05 (SD = 13.80). All differences between the
subsamples on demographic characteristics were non-
significant by chi-square (for the categorical variable)
or t-tests (for the continuous variables).
Measures
The French Ways of Coping Checklist WCC-R
(Cousson et al., 1996) is a 27-item coping scale
assessing three coping strategies (problem-focused
coping; emotion-focused coping; and seeking social
support) and derived from Lazarus and Folkmans
WCC, which was validated by Vitaliano et al.
(1985) in 425 medical students. The French form of
the WCC presents good construct and criterion
validities in the general population (Bruchon-
Schweitzer, Cousson, Quintard, & Nuissier, 1996).
Respondents use a 4-point Likert-type scale ranging
from No to Yes.
The State-Trait-Anxiety Inventory, form Y
(Spielberger, Gorsuch, Lushene, Vaag, & Jacobs,
1983) consists of two scales, one assessing anxiety
as a personality trait (20 items) and the other
assessing anxiety as a state (20 items). The STAI
has been demonstrated to be reliable for the French
population (Bruchon-Schweitzer & Paulhan, 1993).
Table 1. Patient characteristics
Characteristic n %
Age
40 years 64 10.3
4150 years 122 19.6
5160 years 178 28.6
6170 years 160 25.7
> 70 years 98 15.8
Sex
Female 475 76.4
Male 147 23.6
Diagnosis
Breast 372 59.8
Lung 49 7.9
Gastrointestinal 38 6.1
Gynaecological 30 4.8
Bladder 26 4.2
Lymphoma 21 3.4
Head and neck 20 3.2
Melanoma 11 1.8
Nervous system 9 1.4
Prostate 8 1.3
Sarcoma 7 1.1
Hodgkin 5 0.8
Thyroid 1 0.2
Others 25 4.0
Partner status
Un-partnered 137 28.6
Partnered 447 71.4
Stage of the disease
Local 368 59.16
Local-regional 138 22.18
Metastatic 99 15.92
Unknown 17 2.73
COUSSON-GLIE ET AL: THE WAYS OF COPING CHECKLIST (WCC)
1249
Statistical methods
The psychometric properties of the WCC-R
(univariate statistics, internal consistencies) are
presented. The calibration sample was used to perform
two steps. First, a confirmatory factor analysis (CFA)
was performed to test the structural properties of the
27 items for testing the factorial structure initially
identified with non-cancer French subjects. Second, if
CFA did not fit the data, then Exploratory Factor
Analysis (EFA) was conducted followed by
congeneric confirmatory factor analysis to refine the
scales. Finally, a novel CFA on the replication sample
was performed to test the new version. Pearson
product-moment correlation coefficients were
calculated to assess criterion validity.
Confirmatory factor analysis (CFA)
Data obtained from the WCC-R are based on a
4-point Likert-type scale. Although the items
measure a continuous construct, this kind of response
format is considered as ordinal scaled data because it
does not have equally spaced intervals. When
observed variables are ordinal, previous research
findings support a model estimation using polychoric
correlations, which have been found to perform
better than Pearson correlations (DiStefano, 2002;
Flora & Curran, 2004; Gilley & Uhlig, 1993;
Jreskog & Moustaki, 2001, 2006; Kim & Muller,
1978). Furthermore, a recent work by Wirth and
Edwards (2007) demonstrates the importance of
using categorical estimation techniques when using
fewer than five response categories and of comparing
results using various estimation methods. We thus
selected two estimation methods to calculate the
model parameters and fit. The Unweighted Least
Squares (ULS) method has been shown to be fairly
robust (Ximnez, 2007) and the Diagonally
Weighted Least Squares (DWLS) method seems to
perform well across many conditions (Flora &
Curran, 2004). We compared the results from both
methods to determine whether or not the different
methods led to different conclusions. The ULS
method was run using the covariance matrix and the
DWLS method was run by incorporating the
polychoric correlation matrix. The DWLS also
required an estimate of the asymptotic covariance
matrix of the sample correlations.
The covariance, polychoric correlation matrices and
the asymptotic covariance matrix were calculated by
using PRELIS 2.8. Two models were specified and
estimated by using LISREL 8.8: the three-factor model
with 27 items fromCousson et al. (1996) and a newone
based on the EFA results. To test the quality of
adjustment of these models, we selected a chi-square/
degree of freedom ratio smaller than 2.0. To take
account of sample size, we report the Comparative Fit
Index (CFI) and the Adjusted Goodness-of-Fit Index
(AGFI). Values close to .95 were considered to indicate
acceptable model fit (Hu & Bentler, 1999). The Root
Mean Square Error of Approximation RMSEA of less
than .05 indicated good fit, while a value of .08 was not
to be exceeded. We chose to drop items which
explained variance smaller than 0.21, as did Osborne
Elsworth, Kissane, Burke and Hopper (1999) and
Cayrou, Dickes, Gauvain-Piquard and Roge (2003) in
the same type of study. Finally, none of our models
allowed errors between items to correlate.
Exploratory factorial analysis
To select items to form a new version of the WCC,
we based our analysis on the 27-item coping scale
assessing three coping strategies (problem-focused
coping; emotion-focused coping; and seeking social
support). EFA was calculated using the ML method
with Oblique (Promax) rotations on the polychoric
correlation matrix. Items were retained if their
unique variance was < 0.80, their factor loading
> 0.40 or cross-loadings < 0.30 on a second factor.
Because we used polychoric correlations, we checked
for violations of underlying bivariate normality
assumptions using the comparison of Likelihood
Ratio (LR) test statistic and Goodness-of-Fit (GF)
statistic for each correlation when the Root Mean
Square Error of Approximation (RMSEA) was larger
than 0.1 (Jreskog, 2001)
Using the congeneric measurement model, the
three subsamples of items tested using three distinct
submodels hypothesized a single factor explaining
the common variance of the corresponding items
(Cayrou et al., 2003; Nordin, Berglund, Terje, &
Glimelius, 1999).
Results
Reliability and mean value
As assessment of the reliability (internal consistency)
coefficient alpha was computed for the three original
WCC subscales. The reliability coefficients were
comparable with those we reported with non-cancer
subjects (Cousson et al., 1996) with the exception of
seeking social support (see Table 2). Estimates of
reliability (Cronbachs ) were satisfactory for two
original scales, emotion-focused coping ( = 0.76)
JOURNAL OF HEALTH PSYCHOLOGY 15(8)
1250
and problem-focused coping ( = 0.79), with the
exception of seeking social support ( = 0.69). This
suggested that this subscale is in need of
improvement. The mean of social support was
significantly higher in cancer patients than in the
general population (t = 3.98, p < 0.001).
Confirmatory factor analysis (CFA)
Before using the polychoric correlation matrix, we
checked for the assumption of underlying bivariate
normality and found no correlations violating this
assumption. We used a CFAto test the factor structure
initially found by Cousson et al. (1996) where three
factors were identified: problem-focused coping (10
items); emotion-focused coping (9 items); and social
support seeking coping (8 items).
3
The result of CFA
on these 27 items and three oblique factors
hypothesized showed a lack of adjustment. The
indices for the confirmatory factor models for Models
1.a and 1.b (see Table 3), using two distinct methods
but testing this theoretical model (three factors with 27
items), showed an inadequate fit. None of the selected
indices reached the standard chosen and four of the 27
items showed an explained variance lower than 0.21.
Therefore, this model was rejected and not considered
as the best explanation of the data.
Exploratory factor analysis and
congeneric factor analysis
Owing to the lack of adjustment, we ran EFA.
Analysis based on the scree plot did not really show
an elbow in the plot. However, the contributions
were relatively low after the sixth component. In
order to complete our analysis we used a parallel
analysis and retained only those factors whose
actual eigenvalues were greater than the eigenvalues
from the random data. The results indicate that only
the first four eigenvalues were greater than those
generated by parallel analysis (for both the average
and 95th percentile criteria based on 1000 iterations)
and thus had to be initially retained. The results on
the fourth factor were hardly interpretable with only
one item loading on this statistical factor. We finally
retained a three-factor solution. This result agrees
with the preceding conclusion that three factors
provide a reasonable summary of the data and
provide an optimal meaningfully interpretable
solution (Cousson et al., 1996).
Of the 27 survey items, 21 were retained for further
analyses. Three items were considered complex (i.e.
had a high loading on more than one component) and
three others were deleted because their unique
variance was greater than 0.80 (see the last six items in
Table 5). Congeneric factor analysis showed no items
Table 2. Psychometric properties of the WCC subscales
WCC Subscales n M SD
Cousson et al., 1996
Social support (8 items) 468 20.33 4.89 .76
Emotion-focused 468 21.00 5.59 .72
coping (9 items)
Problem-focused 468 27.3 5.79 .79
coping (10 items)
Present study
Social support (8 items) 622 23.93 5.45 .69
Emotion-focused 622 21.11 6.16 .76
coping (9 items)
Problem-focused 622 28.42 6.68 .79
coping (10 items)
Present study
Social support (6 items) 622 18.11 5.15 .79
Emotion-focused 622 14.70 5.12 .74
coping (7 items)
Problem-focused 622 23.05 5.65 .78
coping (8 items)
Table 3. Fit indices for the confirmatory factor models of the WCC questionnaire
Model Method
2
df p
2
/df RMSEA CFI AGFI
Model 1.a: 27 items/ 3 factors ULS 845.40 321 < 0.0 2.63 0.13 1.00 0.92
Model 1.b: 27 items/ 3 factors DWLS 780.05* 321 < 0.0 2.43 0.07 0.94 0.92
Model 2.a: 21 items/ 3 factors ULS 341.86 186 < 0.0 1.84 0.05 0.94 0.94
Model 2.b: 21 items/ 3 factors DWLS 342.96* 186 < 0.0 1.84 0.05 0.98 0.97
Notes:
ULS = Unweighted Least Squares; DWLS = Diagonally Weighted Least Squares;
2
/ df = chi-square - degree of
freedom ratio, RMSEA = Root Mean Square Error of Approximation. CFI = Comparative Fit Index; AGFI= Adjusted
Goodness-of-Fit Index.
* Satorra-Bentler scaled chi-square
COUSSON-GLIE ET AL: THE WAYS OF COPING CHECKLIST (WCC)
1251
whose explained variance was less than 0.21. For each
factor, fit indices showed an acceptable value. We
therefore selected the 21 items.
The three factors explained 37.8 percent of the total
variance. Loadings for this solution are shown in
Table 4. Factor 1 consisted of five items that indicated
seeking social support behavior, including, asking for
advice, for an objective intervention, for the help of a
professional person, and one itemregarding emotional
support (expressing ones emotions). This factor could
be named seeking social support. The second factor
comprised seven items that mainly reflected self-
blame attribution (criticizing or lecturing oneself,
feeling guilty) and avoidance (hoping for a miracle,
feeling bad for not avoiding the situation, trying to
forget everything). This factor was named Self-blame
and Avoidance. The third factor comprised eight items
that indicated an active and optimistic psychological
outlook on the illness, including, fighting spirit,
feeling stronger, taking things one by one, and finding
some solutions. This could be interpreted in terms of
Problem-focused coping.
Confirmatory factor analysis
Confirmatory factor analysis was performed to
analyze the fit of this new 21-item three-factor
solution in the replication subsample (N = 310). The
three-factor solution was also tested with correlated
factors. All regression paths and correlations were
found to be significant. Whatever the method, the
results indicate that the three-factor solution with 21
items fits the data (see Models 2.a and 2.b in Table 3).
Correlations between the new WCC
subscales and reliability
Correlations among the three new subscales showed
Seeking Social Support to be positively associated
with Avoidance and Self-blame (r = 0.25, p <
0.001), and strongly and positively associated with
Problem-focused Coping (r = 0.70, p < 0.001).
Avoidance and Self-blame was also positively
associated with Problem-focused Coping (r = 0.28,
p < 0.001). Estimates of reliability with Cronbachs
(N = 622) were satisfactory for all the new WCC
subscales (see Table 2).
Correlations between the WCC and
anxiety scales
The results showed a positive association between
state anxiety and Self-blame/Avoidance (r = 0.30,
p < 0.001), and a negative association between State
Anxiety and Problem-focused Coping (r = 0.19,
p < 0.001). Trait anxiety was also positively associated
with Self-blame/Avoidance (r = 0.47, p < 0.0001)
and negatively associated with Problem-focused
Coping (r = 0.13, p < 0.01). No significant correla-
tions were found between anxiety scales (trait and
state) and Seeking Social Support (respectively,
r = 0.01, p = 0.77; r = 0.02, p = 0.70).
Comparisons of mean WCC scores
for age, sex, diagnosis, partner
status and stage of the disease
Results on all the subjects (N =622) showed no
significant differences for age on mean WCC scores.
However, women had lower mean scores on the
Seeking Social Support (t = 4.64, p < 0.001) and Self-
blame/Avoidance scale (t = 2.62, p < 0.01) than men.
Breast cancer patients had lower mean scores on
Seeking Social Support (t = 5.60, p < 0.001), on Self-
blame/Avoidance (t = 2.43, p <0.05) and on Problem-
focused Coping (t = 4.82, p < 0.001) than patients
with other types of cancer.
We found no significant differences between
patients living with a partner or those living alone
for the three scores of the WCC (t = 0.20, p = 0.83;
t = 1.13, p = 0.26; t = 1.02, p = 0.29).
Discussion
The present study used a complete procedure to test the
psychometric properties of the WCC in a sample of
French-speaking cancer patients. First, we conducted a
CFA to test the factor structure obtained with 468
healthy French-speaking participants (Cousson et al.,
1996). Results showed that this factor structure did not
fit the cancer patient data, so we conducted an initial
exploratory factor analysis followed by a confirmatory
factor analysis based on a large sample. EFAidentified
a factor structure with three principal dimensions:
seeking social support (6 items); self-blamed
attribution and avoidance (7 items); and problem-
focused coping (8 items). All the items retained
correspond to the original scales of the WCC validated
in French-speaking subjects but some items were
dropped: three items (item numbers 2, 5 and 15) of the
original emotion-focused coping, two items of
problem-focused coping (items numbers 19 and 22)
and one item (item number 21) of the social support
seeking scale. According to current methodological
recommendations, we found a stable factor structure
whatever the method used. The internal consistency of
each of these subscales is satisfactory.
JOURNAL OF HEALTH PSYCHOLOGY 15(8)
1252
Table 4. Factor loading estimates for ML with Promax-rotated factor in calibration sample (N = 310)
Self-blamed Problem-
Social attribution and focused Unique
Items support avoidance coping variance
Q18
a
Talked to someone who could do SS
b
0.86 0.00 0.02 0.28
something about the problem.
Q 12 Talked to someone to find out SS 0.86 0.09 0.09 0.29
about the situation.
Q 09 Asked someone I respected for SS 0.80 0.01 0.02 0.34
advice and followed it.
Q 06 Got professional help and SS 0.57 0.15 0.09 0.64
did what they recommended.
Q 03 Talked to someone about how SS 0.57 0.10 0.02 0.68
I was feeling.
Q 24 Accepted sympathy and SS 0.51 0.03 0.28 0.52
understanding from someone.
Q 14 Blamed myself. E 0.13 0.77 0.23 0.49
Q 26 Criticized or lectured myself. E 0.11 0.77 0.13 0.49
Q 17 Thought about fantastic or unreal E 0.03 0.62 0.11 0.54
things that made me feel better.
Q 11 Hoped a miracle would happen. E 0.18 0.62 0.14 0.59
Q 23 Wished I could change the way that I felt. E 0.08 0.58 0.13 0.62
Q 08 Felt bad that I couldnt avoid the problem. E 0.17 0.54 0.00 0.64
Q 20 Tried to forget the whole thing. E 0.04 0.48 0.09 0.75
Q 27 I know what had to be done, so I doubled P 0.12 0.14 0.84 0.44
my efforts and tried harder to make
things work.
Q 16 Came out of the experience better than P 0.19 0.02 0.72 0.59
when I went in.
Q 01 Made a plan of action and followed it. P 0.07 0.15 0.68 0.63
Q 10 Just took things one step at a time. P 0.07 0.05 0.63 0.57
Q 04 Stood my ground and fought for what P 0.13 0.01 0.60 0.55
I wanted.
Q 25 Came up with a couple of different solutions P 0.18 0.05 0.49 0.62
to the problem.
Q 13 Concentrated on something good that could P 0.17 0.10 0.45 0.64
come out of the whole thing.
Q 07 Changed or grew as a person in a good way. P 0.12 0.23 0.41 0.63
Eliminated items
Q 19 Changed something so things would turn P 0.12 0.36 0.39 0.53
out all right.
Q 02 Wished the situation would go away or E 0.41 0.26 0.09 0.64
somehow be finished.
Q 05 Wished that I could change what had happened. E 0.28 0.41 0.02 0.68
Q 15 Kept my feelings to myself. E 0.40 0.32 0.24 0.80
Q 21 Tried not to burn my bridges behind me, but SS 0.15 0.07 0.17 0.93
left things open somewhat.
Q 22 Tried not to act too hastily or follow my P 0.01 0.08 0.33 0.87
own hunch.
Notes:
Factor loadings > .40 are in boldface
a
Item number in the original WCC
b
Abbreviations for the original WCC subscales: SS, social support; E, emotion-focused coping; P, problem-focused
coping
COUSSON-GLIE ET AL: THE WAYS OF COPING CHECKLIST (WCC)
1253
We found that seeking social support was strongly
and positively associated with problem-focused
coping. This result is consistent with the findings of
Vitaliano et al. (1985) in which problem-focused
coping was correlated with seeking social support
(r = .70). For four items of the seeking social support
scale, the patient solicited someones help in order to
solve the problem: talked to someone who could do
something about the problem, talked to someone to
find out about the situation, asked someone I
respected for advice and followed it, got professional
help and did what they recommended, whereas for
only two items did the patient seek social support to
help them express how they felt. So although the
correlations are high, seeking social support should be
separated from problem-focused coping.
The relationship of the coping scales to partner
status and age were either nonexistent or minimal.
However, gender was significantly related to the
seeking social support score and the Self-blame/
Avoidance scale. These results are partly consistent
with the finding of Cousson et al. (1996) in which
men were more likely to use social support than
women. However, the results about avoidance do not
agree with previous findings that reported higher
scores on avoidance strategies in females than males
(Matud, 2004). Nevertheless, not all these studies
were conducted with cancer patients. We hypothesize
that when confronted with a high stressor like cancer,
women do not avoid the situation. In this study, we did
not expect a difference in factorial structure because
we did not obtain it with the general population
(Cousson et al., 1996), and previous studies using the
WCC did not find any sex differences in coping with
cancer (Dunkel-Shetter et al., 1992).
As pointed out by Nordin et al. (1999), the value of
using the WCC as a measure of coping rather than the
MAC scale developed by Watson et al. (1988) is that
the WCC corresponds to the coping theory developed
by Lazarus and Folkman (1984a, 1984b). Previous
results concerning factor analysis of the MAC are not
congruent. The original structure proposed by Watson
et al. (1988) was not replicated by Schwartz et al.
(1992) on 239 USA cancer patients, nor by Nordin et
al. (1999) in a heterogeneous Swedish sample of
cancer patients (n = 868).
The subscales of the MAC contain components of
mental adjustment like threat and anxiety, which are
arguably not coping strategies but rather an emotional
reaction to diagnosis and illness. While the anxious
preoccupation subscales of the MAC focus more on
outcomes, Lazarus pointed out the importance of
separating appraisal, coping and outcome (Lazarus &
Folkman, 1984a). In our clinical experience, some
MAC items were judged by patients as shocking (I
dont have cancer). Another limitation with the
research on coping with cancer using the MAC scale,
as suggested by Nordin et al. (1999), is that it
confounds coping with distress outcome.
The negative correlation between the WCC
problem-focused coping scale for cancer patients and
anxiety and the positive correlation between avoidant/
self-blame and anxiety are consistent with previous
findings (Ben-Zur, 1999; Cousson-Glie, 2000; David
Table 5. Means (and standard deviation) for WCC scores depending on age, sex, diagnosis, partner status of cancer patients
N Seeking social support Avoidance/Self- blame Problem-focused coping
Age
40 years 64 15.44 (4.18) 14.84 (5.31) 23.58 (5.17)
4150 years 122 14.25 (4.45) 14.51 (5.06) 22.47 (5.47)
5160 years 178 14.48 (4.91) 14.20 (5.02) 23.49 (5.67)
6170 years 160 14.67 (4.52) 14.93 (4.78) 22.86 (5.46)
> 70 years 98 15.39 (4.61) 15.13 (5.78) 23.74 (5.67)
Sex
Female 475 14.30** (4.69) 14.59 (5.18) 22.86** (5.63)
Male 147 16.13** (4.03) 14.99 (4.93) 24.22** (5.05)
Diagnosis
Breast cancer 376 13.84* (4.77) 14.33* (5.23) 22.31* (5.67)
Other cancer 246 15.89* (4.16) 15.36* (4.96) 24.45* (5.10)
Partner status
Un-partnered 137 14.78 (4.89) 15.05 (5.34) 23.5531 (5.97)
Partnered 447 14.70 (4.49) 14.53 (5.02) 23.0293 (5.34)
*p < 0.05; **p < 0.01
JOURNAL OF HEALTH PSYCHOLOGY 15(8)
1254
et al., 2006; Schnoll et al., 1998) and support our
hypotheses about the relationship between coping
factors and outcome. The absence of relation between
anxiety scales and Seeking Social Support was also
found with non-cancer French subjects (Cousson
et al., 1996). Such findings are more surprising with
cancer patients. Previous studies showed that emotional
social support from family and friends is associated
with good adjustment to the disease (Alferi, Carver,
Antoni, Weiss, & Durn, 2001; Dunkel-Schetter, 1984;
Funch & Marshall, 1983; Hoskins, Baker, Sherman, &
Bohlander, 1996; Moyer & Salovey, 1996; Neuling &
Winefield, 1988; Northouse & Swain, 1987; Parker,
Baile, De Moor, & Cohen, 2003). However, those
studies evaluated perceived social support but not social
support as a coping strategy. One study noted that
cancer patients who reported more stress seek more
social support (Dunkel-Schetter et al., 1992).
Unfortunately, coping strategies and anxiety are
assessed at the same time and it is impossible to unravel
whether one leads to the other. Further longitudinal
research is needed to test the relationship between the
subscales of this WCC adapted for cancer patients and
a range of psychosocial outcomes such as anxiety,
depression and quality of life. Another aspect to be
considered in future research is the relative
inconsistency of coping strategies over time.
The present findings represent a first step towards
a valid measure of the WCC in a sample of French-
speaking cancer patients. This short 21-item version
of the WCC is easier to use in a protocol than the
initial 27-item version. However, a single study is
not a sufficient basis for establishing the construct
validity of an instrument. Comparisons in other
samples and relationships with other measures of
similar constructs will be included in further studies.
Notes
1. The COPE (Carver, Scheier, & Weintraub, 1989)
consists of 13 scales: five scales assessing problem-
focused coping, five scales assessing emotion-focused
coping and three scales assessing focusing on and
venting emotion, behavioral disengagement, and
mental disengagement.
2. The Mental Adjustment Cancer (MAC) scale was
then developed to evaluate adjustment styles in
clinical trials (Watson et al., 1988) following the
publication by Greer, Morris and Pettingale (1979) of
a link between coping strategy (i.e. fighting spirit) and
length of survival. A French validation of the MAC
retained only three dimensions: fighting spirit;
hopelessness/helplessness; and anxious preoccupation
(Cayrou, Dickes, Gauvain-Piquard, & Roge, 2003).
3. The authors administered the WCC (42 items)
validated by the Vitaliano et al. (1985) questionnaire to
468 adults French subjects (males and females). A
principal component analysis followed by varimax
rotations yielded three factors accounting for about 35
percent of the total variance. They were interpreted as
Problem-focused, Emotion-focused and Social-support
Seeking types of coping. Fifteen items were dropped.
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FLORENCE COUSSON-GLIE, PhD, has been a senior
lecturer in Health Psychology since 1998 at the
University of Bordeaux 2 (France). Her studies
focus on cancer patients quality of life, coping
strategies, locus of control, social support and
psychosocial interventions. She also studies the
impact of cancer on family relationships.
OLIVIER COSNEFROY is study engineer and data
manager at the University of Bordeaux 2. He
collaborates on research projects in health
psychology and child development.
VRONIQUE CHRISTOPHE, PhD, is a lecturer in
Social and Health Psychology at Lille North of
France University. Her research interests include
self and social regulation of emotion, its
consequences on interpersonal relationships, and
on chronic disease, especially on cancer.
CARINE SEGRESTAN-CROUZET is a PhD student at
Bordeaux 2 University (France) and Psychologist
at the Libourne Hospitals Oncology Unit. Her
clinical and research interests include the role of
transactional variables, such as social support and
coping strategies, in women and couples coping
with breast cancer, patient education, and
cognitive-behavioral therapy.
ISABELLE MERCKAERT has been Assistant Professor
at the Universit Libre de Bruxelles since 2008
(Belgium) and collaborates actively on research
projects in the field of physician-patient
communication in cancer care. She also works part-
time as a clinical psychologist in the Belgian cancer
centre Institut Jules Bordet. Her main focus of
interest lies in the relationships of health-care
professionals with patients and their families in
cancer care. More precisely, her research topics
focus on how to improve physicians
communication skills with cancer patients and their
families and on the exchange of information in the
context of informed consent in cancer clinical trials.
EMMANUELLE FOURNIER is a psychologist and
research engineer at Lille North of France
University. She works with the staff of Famille,
Sant, Emotions, especially in cancerology.
YVES LIBERT, PhD, is Master of Lectures at the
Universit Libre de Bruxelles (Belgium) and
collaborates actively on research projects in three
main fields: oncogeriatry; clinical support given to
the patient and their relatives; and physicianpatient
communication in cancer care. He is also a clinical
psychologist at the Belgian cancer centre Institut
Jules Bordet. One of his main research topics focuses
on how to improve the psychological support given
to cancer patients and their informal caregivers.
ANAS LAFAYE received her PhD in Psychology in
2009 at the University of Bordeaux 2, in France. Her
research interests concern prostate cancer patients
and their spouses quality of life and emotional state,
and the actor and partner effects of social support,
coping strategies and dyadic adjustment on quality
of life, anxiety and depression.
DARIUS RAZAVI is a neuro-psychiatrist and
Professor at the Universit Libre de Bruxelles. He
is at present the director of a Psychosomatic and
Psycho-oncology Research Unit (PPRU) at the
Universit Libre de Bruxelles and the head of the
Psycho-oncology, Pain and Palliative Care Clinic at
Institut Jules Bordet, Cancer Center of the
Universit Libre de Bruxelles. His research focuses
on the interface of psychiatry and oncology:
communication skills, screening of psychiatric
disorders, treatment of anxiety and depression,
psycho-endocrinology and smoking cessation.
Author biographies