ORIGINAL ARTICLE

Relationship between hopelessness, loneliness, and perceived

social support from family in Turkish patients with cancer
Seda Pehlivan & Ozlem Ovayolu & Nimet Ovayolu &
Alper Sevinc & Celalettin Camci
Received: 3 September 2010 / Accepted: 6 March 2011 / Published online: 1 April 2011
# Springer-Verlag 2011
Abstract
Purpose Life-threatening diseases such as cancer can create
hopelessness and loneliness by altering the lifestyle of the
patient and family. Perceived social support may facilitate
coping with illness. The aim of this study was to investigate
the relationship between hopelessness, loneliness, and
perceived social support from family in Turkish patients
with cancer.
Methods This study involved 188 patients with cancer. The
data were collected using a questionnaire that determined
the sociodemographic features, the Beck Hopelessness
Scale, the UCLA Loneliness Scale, and Perceived Social
Support from Family Scale. Data were evaluated with
MannWhitney U and KruskallWallis and Spearman
product moment correlation coefficients.
Results The mean scores of hopelessness (020), loneliness
(2080), and perceived social support from family (020)
were 6.80.4, 35.80.8, and 15.20.2, respectively. A
statistically positive relationship existed between hopeless-
ness and loneliness. A negative relationship between
loneliness, hopelessness, and perceived social support from
family was found (p<0.05). Cancer patients who had
family history of cancer and long disease duration had
low social support from family. The hopelessness score was
significantly higher in female, older, illiterate, and village-
dwelling cancer patients.
Conclusions In cases where the perceived social support
levels were determined to be high; the cancer patients
were not hopeless or lonely. We found that decreased
social support was associated with increased loneliness
and hopelessness. The present evaluation indicates that
although the levels of perceived social support of
patients from their families may be sufficient to
prevent loneliness or hopelessness, these parameters
need to be evaluated periodically to maintain the
patients' well-being.
Keywords Hopelessness
.
Loneliness
.
Social support
.
Turkish cancer patient
Introduction
Cancer is one of the major causes of death around the
world, and receiving a diagnosis of cancer is an
extremely stressful experience [1]. While advances in
cancer screening and treatment have resulted in an
increased number of survivors, a diagnosis of cancer
nevertheless causes significant emotional trauma to
patients, who often experience increased feelings of
vulnerability, loss of control, and uncertainty about their
future [2]. Several studies have indicated that a patient's
coping response to having cancer is an important deter-
minant of psychological morbidity [3]. Psychological
distress is frequently observed in cancer patients during
the clinical course of this disease. The prevalence of
psychiatric disorders following a primary diagnosis of
cancer has been reported to range from 14% to 38% [4].
Depression is a common psychiatric disorder in cancer
patients [5], while loneliness and hopelessness have been
associated with depression [6].
S. Pehlivan (*)
:
O. Ovayolu
:
N. Ovayolu
Department of Nursing, School of Health, Gaziantep University,
Gaziantep TR-27310, Turkey
e-mail: pehlivan.seda@hotmail.com
A. Sevinc
:
C. Camci
Departments of Medical Oncology, Gaziantep Oncology Hospital,
School of Medicine, Gaziantep University,
Gaziantep TR-27310, Turkey
Support Care Cancer (2012) 20:733739
DOI 10.1007/s00520-011-1137-5
Hopelessness
Hope has been shown to be an important factor in the lives
of cancer patients. Feelings of hope can improve physical
and mental well-being and are a vital factor in healing, in
coping with stress, and in enhancing quality of life during
periods of high stress [7, 8]. In contrast, hopelessness has
been associated with diminished physical, psychological,
mental, and spiritual health [7]. Hopelessness is also
characterized by persistently negative feelings and expect-
ations about the future as well as loss of motivation. A
sense of hopelessness seems to lead to increasingly
negative evaluations of new situations and less effective
coping strategies; thus, the perception is that one will not
accomplish anything meaningful [9]. The feeling of
hopelessness is a key variable that links depression to
suicidal ideation and to suicide in patients with cancer [8].
A realistic hope, felt with the awareness of the problem, is
an important factor for coping with the existing problems of
the patient in an efficient manner [9].
Loneliness
Cancer patients are particularly prone to feelings of
loneliness, and this is a major factor in the mental health
of cancer survivors. A negative association between
loneliness and the level of physical ability, social skills,
and social anxiety has been found [10].
Suggestive evidence supporting a possible link between
loneliness and cancer has been documented. Deficiencies in
perceived social ties mean that the physiological systems of
lonely individuals may absorb more of the impact of
stressors encountered in daily life. Loneliness may indi-
rectly threaten health, as when loneliness results in reduced
medical compliance, obscured symptoms, and an increase
in the delay, and less likelihood, of seeking care [11].
Loneliness causes a weakening in the social status of a
person; impaired interpersonal relationships such as a
person's relationships with family, friends, and relatives;
an increase in negative behaviors; development of emotions
such as distrustfulness and suspicion; and a reduction in
self-trust [9, 12].
Social support
Social support has been defined in the literature as the
assistance and protection given to others, especially to
individuals. Support and assistance from family members is
helpful in aiding the patient cope with stress resulting from
the disease and treatment. Scientists have for many years
recognized a positive relationship between social support
and health [13]. Social support is well documented as one
of the most popular and preferred modes of coping with
loneliness and hopelessness; indeed, this is also indicated in
the general population [14]. There is apparent debate as to
the relative importance of social support, including instru-
mental, emotional, and informational support, versus social
networks, the ties through which support is provided to
cancer survival [15]. Social support, spiritual support, and
disease-related factors like metastasis, performance status,
and duration of cancer diagnosis need to be considered in
nursing intervention in order to maintain a fighting spirit
and to overcome feelings of helplessness/hopelessness and
loneliness in cancer patients [16].
Determining the perceived levels of social support from
the family and the levels of hopelessness and loneliness of
individuals with cancer is important in planning the care for
these patients, in ensuring the contribution of families, and
in increasing life quality, thereby increasing the quality of
care. Investigation of intercultural concepts such as hope-
lessness, loneliness, and social support in our country and
their comparison to results from studies conducted in other
cultures are also believed to have potential to add new
dimensions to these concepts, in addition to contributing to
science and providing direction for future studies. The
purpose of the current study was to define the relationship
between different demographic variables and hopelessness,
loneliness, and social support. Our aim was to determine
whether differences exist in the feelings of loneliness and
hopelessness of Turkish cancer patients in Gaziantep and
how these conditions might be related to their perceived
social support from family.
Materials and methods
A cross-sectional and descriptive correlational design was
used. This study was conducted on 188 Turkish-speaking
patients (18 years of age or older) who had been diagnosed
with cancer at least 2 months before the interview.
Eligibility criteria included no known psychiatric or
neurological disorders that would interfere with completion
of the measures, not being in a terminal phase of the illness,
and currently receiving treatment for cancer in the hospital.
Exclusion criteria were determined taking into account the
factors that might influence the dependent variables of the
study.
The questionnaires were handed out to the patients by
researchers upon arrival at the hospital as outpatients.
Informed consent was obtained from all patients.
The questionnaires included a demographic question-
naire, the Beck Hopelessness Scale (BHS), UCLA Loneli-
ness Scale, and the Perceived Social Support from Family
Scale (PSS-Fa). The demographic questionnaire was used
to assess patients' basic information such as gender, age,
marital status, employment, education, and place of
734 Support Care Cancer (2012) 20:733739
residence. Medical information regarding cancer stage, the
time passed since diagnosis, treatment, and family history
of cancer were recorded. The researchers contacted each
patient and gave a verbal explanation of the study. Patients
were given a questionnaire that they were asked to fill out
independently. If a patient was unable to complete the
questionnaire on his or her own, the researcher read the
questionnaire items to the patient and recorded the answers.
The questionnaires (demographic questionnaire, BHS,
UCLA Loneliness Scale, PSS-Fa) took approximately
30 min for participants to complete.
Hopelessness was assessed with the Beck Hopelessness
Scale [17], a 20-item questionnaire that assesses hopeless-
ness by measuring participants' negative expectancies about
future events. The response format for the BHS is true/false.
Beck Hopelessness Scale scores can range from 0 to 20. A
high score indicates a high feeling of hopelessness. Evidence
indicating a coefficient of 0.93 and a correlation of 0.74
between BHS scores and clinicians' hopelessness rating
supports the reliability and validity of the BHS. The scale
developed by Beck et al. was adapted for Turkey by Durak
in 1994 [18].
The UCLA loneliness scale is a 20-item summated rating
scale that measures the subjective experience of loneliness
[19]. It was adapted by Demir [20] for use specifically with
Turkish people. Total scores on this four-point scale can
range from 20 to 80. The scale consists of 10 negatively
worded items. Higher scores indicate higher loneliness.
Reported Cronbach's alpha was 0.94; testretest reliability
above 2 months was 0.73; good construct and discriminant
validity have been reported [19]. This scale was well
validated in a previous study [20]. In the current study, the
Cronbach's alpha value for patients was 0.74.
The Perceived Social Support from Family scales,
developed by Procidano and Heller [21], were intended to
measure the extent to which an individual perceives that
his or her needs for support, information, and feedback are
fulfilled by family. Each scale consistsof 20 statements, to
which the individual responds to three response alterna-
tives: yes, no, and do not know. For each item, the
response indicative of perceived social support is scored as
+1; that is, scores range from 0 (no perceived social
support) to 20 (maximum perceived social support provid-
ed by family). The do not know response category is not
scored. Eskin [22] documented testretest reliability of
0.85 for the PSS-Fa.
The data were recorded and analyzed using SPSS for
Windows version 13.0 software (SPSS, Inc., Chicago, IL). The
cases distribution evaluated by KolmogorovSmirnov test and
according to the results of this test, there was abnormal
distribution. For that reason, we have used nonparametric tests
for statistical evaluations. MannWhitney U and Kruskall
Wallis tests were used for sociodemographic characteristics
and relationship between loneliness, hopelessness, and per-
ceived social support from family score. The relationship
between loneliness, hopelessness, and perceived social sup-
port from family were analyzed by the Spearman product
moment correlation coefficients. p<0.05 was considered as
significant.
Results
Subjects
The mean ages of the patients were 44.61.1 years, and
duration of disease was 17.21.7 months. Table 1 shows
the patient distributions according to sociodemographics
and clinical characteristics of level of hopelessness,
loneliness, and perceived social support from family. In
total, 51.6% of patients were male, 42% graduated from
primary school, and 79.8% were married. The most
common type of cancer was gastrointestinal cancer
(22.3%), 66.5% of patient received chemotherapy, and
20.7% had cancer history in their family.
Relationship between sociodemographic characteristics
and hopelessness
The mean score of hopelessness of the cancer patients was low.
There was a significantly lower score in male than female
patients (p<0.05). The mean score of hopelessness was also
significantly lower in patients who graduated from university,
who lived in a city and who had local cancer (p<0.05).
However, there was a statistically positive relationship
between hopelessness and age (p<0.05). No significant
relationship was found between the other patient character-
istics (marital status, cancer site, treatment, family history of
cancer, duration of disease) and hopelessness score (p>0.05).
Relationship between sociodemographic characteristics
and loneliness
The mean score of loneliness was moderate. There was a
significantly lower score in local stage of disease com-
pared to other groups (p<0.05). No significant relationship
was found between the age, gender, education, marital
status, place of residence, cancer site, treatment, family
history of cancer, or duration of disease, and loneliness
score (p>0.05).
Relationship between sociodemographic characteristics
and perceived social support from family
The mean score of the cancer patients for perceived social
support from family was high. No significant relationship
Support Care Cancer (2012) 20:733739 735
was found between age, gender, education, marital status,
place of residence, cancer site, stage of disease, or treatment
and perceived social support from family score (p>0.05).
Perceived social support from family level score was
significantly lower if there was a cancer history in the
family. A statistically significant inverse relationship was
also observed between disease duration and perceived
social support from family (p<0.05).
Table 1 Distributions of level of hopelessness, loneliness, and perceived social support from family according to characteristics of patients
Characteristics n (%) Hopelessness, meanSE Loneliness, meanSE Social support, meanSE
Gender
Female 91 (48.4) 7.70.6 35.11.1 15.20.3
Male 97 (51.6) 6.00.5 36.41.1 15.30.3
MWU=2.203, p=0.028 MWU=0.926, p=0.354 MWU=0.215, p=0.830
Education
Illiterate 51 (27.1) 9.10.8 35.61.4 15.90.4
Primary school 79 (42.0) 6.34.9 34.61.0 15.40.4
High school 41 (21.8) 6.05.1 36.72.0 14.50.5
University 17 (9.1) 4.21.2 39.63.5 14.00.9
KW=14.153, p=0.003 KW=0.920, p=0.821 KW=7.121, p=0.068
Marital status
Married 150 (79.8) 6.80.4 35.60.9 15.40.2
Single 38 (20.2) 7.01.0 36.71.8 14.40.6
MWU=0.147, p=0.883 MWU=0.788, p=0.430 MWU=1.575, p=0.115
Place of recidence
City 129 (68.6) 6.10.4 35.81.0 15.00.3
Town 36 (19.2) 8.20.9 36.31.5 15.60.4
Village 23 (12.2) 8.41.2 35.01.8 16.00.5
KW=7.614, p=0.022 KW=0.419, p=0.811 KW=0.928, p=0.629
Cancer site
Lung 30 (16.0) 8.00.9 37.62.2 14.30.7
Hematologic 37 (19.7) 5.20.9 36.31.6 15.10.4
Gastroenterologic 42 (22.3) 7.80.9 36.21.6 15.10.6
Breast 35 (18.6) 6.20.8 33.21.8 16.30.5
Urologic 24 (12.8) 6.41.0 33.52.1 16.00.5
Dermatologic 20 (10.6) 7.61.3 38.72.8 14.20.7
KW=9.829, p=0.080 KW=7.555, p=0.183 KW=8.347, p=0.138
Stage of disease
Local 34 (18.1) 4.50.9 30.21.1 16.20.5
Regional 78 (41.5) 6.30.5 36.01.3 15.50.4
Metastatic 76 (40.4) 8.30.6 38.11.3 14.50.4
KW=16.340, p=0.000 KW=14.310, p=0.001 KW=8.537, p=0.054
Treatment
Chemotherapy (C) 125 (66.5) 6.80.5 36.31.0 14.80.3
Radiotherapy (R) 7 (3.7) 9.72.4 38.04.7 15.71.6
Operation+C+R 56 (29.8) 6.60.6 34.31.3 16.10.4
KW=1.868, p=0.393 KW=1.343, p=0.511 KW=5.709, p=0.058
Family history of cancer
Yes 39 (20.7) 8.10.8 38.01.8 14.20.6
No 149 (79.3) 6.50.4 35.20.8 15.50.2
MWU=1.398, p=0.162 MWU=1.153, p=0.249 MWU=1.704, p=0.048
Toplam 188 (100.0) 6.80.4 35.80.8 15.20.2
MWU Mann Whitney U; KW Kruskall Wallis
736 Support Care Cancer (2012) 20:733739
Relationship between type of treatment and hopelessness,
loneliness, and perceived social support from family
Patients who had radiotherapy were determined to be more
hopeless and unhappy, in addition to having low social
support, when compared with patients who recieved other
treatment methods (received chemotherapy and received
surgery, chemotherapy and radiotherapy together); how-
ever, these results were not stastically significant (p>0.05)
Relationship between hopelessness, loneliness,
and perceived social support from family
The correlation coefficients of hopelessness, loneliness, and
perceived social support from family are displayed in
Table 2. While there was a statistically positive relationship
between hopelessness and loneliness, there was a statisti-
cally negative relationship between hopelessness and
perceived social support from family. There was also a
statistically inverse relationship between loneliness and
perceived social support from family (p<0.05).
Discussion
In cancer patients, social support has been claimed to have
a buffering effect on psychological problems, physical
adaptation, progression of illness, and quality of life [23].
According to many studies, social support received from
parents, friends, and healthcare providers is the most
important resource for patients with cancer [13, 2426]. In
particular, support given by family or a partner has been
demonstrated to improve adjustment to somatic illness and
to predict better quality of life for cancer patients [1].
Vellone et al. [27] and Tan and Karabulutlu [13] reported a
statistically significant inverse relationship between social
support and hopelessness. The current study reflects similar
findings, as the absence of feelings of hopelessness and
loneliness in patients included in our study can be
explained by the high levels of social support they receive
from their families. The present results can be explained at
least in part by the cultural structure of the area where the
study was conducted, which is characterized by strong
familial relationships and cohabiting of individuals within
families. Almost all families in Turkey are linked by a
blood relationship, and most Turkish people value family
intimacy and family cohesiveness. The family first
ideology might have motivated family members to help to
maintain and improve their family member's health. There
is a strong tradition in Turkish culture for respecting and
protecting other family members [6]. In the Southeastern
Anatolia Region, where the hospital in the present study is
located, rather than a nuclear family, an extended family
structure is present. When compared with the Western
regions of the country, family relationships are much more
stronger and supportive. The high levels of support can be
explained by this sociocultural property.
Nausheen and Kamal [26] showed that familial social
support was higher in younger than in older patients with
cancer. However, Tan and Karabulutlu [13] reported no
significant difference between social support from family
and patients characteristics. We determined that perceived
social support from family was significantly lower in
patients with long disease duration and with cancer history
in their family. During the initial periods of the disease,
family members often push their limits to provide any type
of support in order to accompany the patient and solve
possible problems that may arise as the patient adjusts to
treatments. However, over time, this level of support
decreases as family members grow accustomed to the
condition or as the disease becomes an increased burden on
the family. In addition, the presence in the family of more
than one person diagnosed with cancer may also cause
division of support, as well as an increased burden on
caregivers, leading to decreased family support. Insufficient
levels of social support cause unhappiness in cancer
patients [27]. A number of studies have determined that
unhappiness levels of patients are affected by certain
variables, including hope.
Hope is an important component that drives cancer patients
to continue treatment and that makes them feel better [9].
Ballard et al. [28] found that married and male patients with
cancer experienced higher levels of hope. Rustoen et al. [29]
reported that older and low education level patients with
cancer had a significantly higher hopelessness score. Tan and
Karabulutlu [13] found no significant difference between
Hopelessness Loneliness Social support
r p r p r p
Age 0.295 0.000 0.051 0.486 0.073 0.322
Duration of disease 0.083 0.260 0.070 0.337 0.205 0.005
Hopelessness 0.310 0.000 0.354 0.000
Loneliness 0.310 0.000 0.213 0.003
Table 2 Correlation coefficient
of hopelessness, loneliness, and
perceived social support from
family
Support Care Cancer (2012) 20:733739 737
hopelessness and patients characteristics. In the present
study, we showed that hopelessness score was significantly
higher in female, older, illiterate, and rural cancer patients.
The high level of hopelessness in women can be explained
by the adoption of the man as the head of the family in
Turkish society. Men play important roles in protecting
family integrity and also have a greater social network
compared to women. In the elderly, their expectations of
actually accomplishing their future plans and goals may
already be low and this may be the cause for their feelings of
hopelessness. In the case of education, higher education
levels may be associated with greater knowledge about
protecting and developing health, which increases the sense
of responsibility in the patient, thus decreasing the sense of
hopelessness. In our study, the higher levels of hopelessness
of individuals living outside of major cities may be
explained by difficulty in sufficiently accessing health care
and legal social support institutions.
Stressful events such as pain and disease metastasis have
also been reported to impact the level of the human spirit/
morale and thereby could cause hopelessness [7]. There was a
significant difference between the hopelessness and loneli-
ness scores of the patients with metastatic disease and those
with local and regional disease, signifying that the patient's
disease stage affected their level of hopelessness. The
hopelessness score in patients who had metastatic disease
was higher than in those with local and regional disease. This
finding was consistent with reports in the literature [7, 8].
Patients who experienced high levels of psychosocial
stress at the start of radiotherapy also displayed the same
high level of stress during and after therapy, and required
constant psychosocial support to improve their quality of
life [30]. In this study, although not statistically significant,
patients who received radiotherapy experienced more
hopelessness and loneliness compared to patients receiving
other types of treatment, also, they were observed to have
less social support than the group that received triple
therapy. Based on these results, it can be recommended that
especially patients who receive radiotherapy treatment to be
evaluated for psychiatric problems, radiotherapy team to
collaborate with the patient's family to strengthen the social
support of patients, and to include patients receiving
radiotherapy, in these type of research.
Significant associations between higher scores of lone-
liness and psychological distress were detected in several
studies of subjects with various cancers at different clinical
stages [4]. Rustoen et al. [29] reported that hope scores
were significantly lower among those living alone than
among those living with someone. In our study, we found
that the mean score of loneliness was moderate and that no
relationship existed between patient characteristics and
loneliness score. The average levels of loneliness can be
explained by high levels of social support and low levels of
hopelessness. Those patients who have sufficient social
support and who can make plans for the future may
experience less loneliness by building an intense commu-
nication with their environment.
Conclusion
In the present study, we found that decreased social support
from family resulted in increased loneliness, which in turn
increased a sense of hopelessness in cancer patients. Social
support of cancer patients from family is the most influential
factor in overcoming feelings of hopelessness and loneliness.
For this reason, it is important that nurses do not ignore the
social support systems of patients when evaluating their
hopelessness and loneliness status. In particular, cancer
patients who had family history of cancer and long disease
duration tended to have low social support from family
members. Close surveillance of these patients by nurses may
decrease problems that may arise over the long term.
Hopelessness score was also significantly higher in the
female, older, illiterate, and village-dwelling cancer patients.
Due to the patriarchal structure of the traditional Turkish
culture, the support of female patients in particular and the
planning of initiatives that provide a more hopeful perspec-
tive of the future for the older, not as well-educated patients
who live in rural areas should be the basic functions of
nurses. However, cultural differences may appear from
country to country and even from one region to another in
the same country. For this reason, while providing care for
cancer patients, nurses should not generalize; evaluation of
the cultural characteristics of a patient's surroundings, social
support systems, and family structure may facilitate more
beneficial and desirable care results.
Limitation of the study
Since this study was conducted in Gaziantep, which is the
biggest province of Southeastern Anatolia Region of
Turkey, it might reflect the characteristics of this region.
Since especially those living in the Western regions of the
country have different sociodemographic and cultural charac-
teristics, this study cannot be generalized to the country.
Conflict of interest There is no conflict of interest.
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