ASSESSMENT OF THE LEVEL OF DISTRESS AND PRACTICAL AND FAMILY PROBLEMS IN PATIENTS WITH ONCOLOGICAL DISEASES

Purpose: To study and analyze the relationship be-tween patients’ practical and family problems and the level of distress. Material/Methods: A “Distress Thermometer” was used to collect information from the patient to assess the degree of distress. Inclusion and exclusion criteria for the patients were applied. Methods for statistical processing of the data and interpretation of the results were used. Results: The study included 225 patients with an average age of 59.6 (+/- 11.4 years). Women are a little over half, 56% (n=126) of the total number of those examined. All patients have a histologically confirmed oncological diagnosis in stage II, III and IV. It was found that there was no relationship between the level of distress and childcare (p= 0.93). In a more in-depth analysis of the results, a significantly higher level of distress was found in patients who encountered difficulties with transportation to the medical facility (p=0.01). A significantly higher level of distress was reported in patients who marked the relationship with their partner as problematic (n=13, 5.8%) (4.7±3.9). Conclusion : The diagnosis and treatment of cancer have more than just a physical impact. Health care should be comprehensive based on the needs of the patient. It is also necessary to consider the psycho-social and emotional support provided by medical professionals.


INTRODUCTION:
Every year, millions of people around the world are diagnosed with oncological diseases.Oncological diseases are subject to multi-complex treatment [1,2].Oncology care also includes complementary therapies, which are gaining more and more popularity among both people and health professionals.The key role that health care professionals have in relation to complementary care is to provide patient support, information provision, education, etc. [2, 3, 4, 5,6].The reason patients and their families turn to complementary therapies is because they are looking for an alternative to conventional treatment or want to improve their quality of life.The advantage of complementary therapies is that they affect the whole person.The advantage of complementary therapies is that they work entirely on the person.Making the decision to have additional therapy can improve options and create a sense of control and choice.A person's daily life is usually accompanied by a number of activities.Some of them are related to family functioning, professional activity, personal appearance, etc.In their daily life, patients with oncological diseases solve tasks related to the household, children, professional environment, etc.The disease affects the daily activities of the patient but also of his relatives [7,8,9,10].
Each patient diagnosed with an oncological disease experiences distress to varying degrees, depending on a number of factors, such as gender, age, stage of the disease, etc. Distress is dynamic, its level changes during the course of the disease.Interest in screening for distress in cancer patients is growing significantly [11,12,13].Screening mechanisms and the role of individual health professionals are still evolving and subject to discussion.
The main activity of the oncology care team usually emphasizes the maintenance of life.This issue is of paramount importance to patients and their families.Integrating assessment of social issues into oncology practice is a challenge.

PURPOSE:
To study and analyze the relationship between patients' practical and family problems and the level of distress.

MATERIAL/METHODS:
To assess the degree of distress among the studied patients, a Distress Thermometer was used, in which the patient chooses a number from the visual-analog scale (from 0 to 10) and a questionnaire based on problems related to the patient's daily life, such as each of the questions are marked "Yes" or "No".Inclusion and exclusion criteria were applied for patients included in the study.Some of the patients dropped out due to proven distress and a visit to a psychologist, refusal to participate in the study, evidence of an accompanying illness leading to distress, and incomplete information in the documentation that compromises the analysis.Thus, the self-assessment of problems arising in everyday life was performed on he patients n=225, UMHAT St. Marina, Varna.Methods for statistical processing of the data and interpretation of the results (non-parametric analyses, correlation analysis, variation analysis, dispersion analysis) were used.

RESULTS:
The data from the conducted study show that the average age of the patients included in our study is 59.6 years (+/-11.4years), with the minimum age being 29 years and the maximum age being 81 years.Women are just over half, 56% (n=126) of the total number of respondents.All patients have a histologically confirmed oncological diagnosis in stage II, III and IV.When analyzing the collected data, we found a minimal difference between the respondents in stage II/III, non-metastatic (46.2%, n=104) and IV metastatic stage (53.7%, n=121) (table 1).The subjects had to answer each of the questions, noting (1 -"Yes" or 2 -"No") whether, during the past week, including the day of filling out the questionnaire, any of the listed factors was a problem for them.The survey card under the rubric "practical problems" lists problems related to childcare, housework, insurance/financial problems, transportation, work/school.The part of the questionnaire related to problems of a family nature lists those affecting family relationships.The patients had to indicate whether they felt problems in their relationships with their loved ones.

Assessment of practical problems and family problems:
The analysis of the results shows that the majority of oncological patients included in the study have no difficulties with childcare (n=204, 90.7%).Only 9.3% (n=21) of patients encountered difficulties.It was found that there was no relationship between the level of distress and childcare (p= 0.93).Figure 1 shows the relationship between levels of distress and childcare in the family.The ordinate shows the level of distress, and the abscissa shows the patients' yes (1) or no (2) answers to the question about difficulties with childcare.Analysis of the data on the ability of patients to cope with housework did not establish a significant relationship with the measured level of distress (p>0.05).There were fewer patients (n=46, 20.4%) (4.2±3.2) who had difficulty doing their usual household chores than those who answered the question negatively (n=179, 79.6%) (3.7±3.0).The Chi square test showed no relationship between demographic, clinicopathological characteristics and patients reporting problems with "housework".Regression analysis did not demonstrate an association between high levels of distress and difficulty doing housework (OR 2.2,95% CI 0.85-5.6,p=0.1).It often happens that cancer patients experience serious financial problems related to the costs of their care, even if they have continuous health insurance rights.Some patients indicated that they encountered difficulties in dealing with insurance and finances (n=19, 8.4%), but this did not affect the levels of distress in the subjects (p=0.55)(Figure 2).

Fig. 2. Distribution of patients according to levels of distress and financial difficulties.
The ordinate of the Box plot graph shows the level of distress, and on the abscissa, the patients answered "yes" (1) or "no" (2) to the question related to financial difficulties.
Part of the non-medical expenses for patients with oncological diseases includes the provision of transportation to treatment centers.The distance from the oncology center impacts the patients and their relatives.When analyzing the data, we found that the majority of the examined persons did not indicate the transportation to the medical facility as a problem (n= 199, 88.4%).Although significantly fewer cancer patients noted transportation as a problem (n=26, 11.6%), they should not be ignored.In a deeper analysis of the results, a significantly higher level of distress was found in the patients who encountered difficulties with transportation, at the expense of those who answered the question negatively (p= 0.01) (Figure 3).On the abscissa of the Box plot graph, the patients who answered "yes" (1) and "no" (2) are shown, and on the ordinate their level of distress.and to direct attention to this, although a small group of patients, for whom relationships with children have deteriorated and are a stressogenic factor -regardless of whether are long term or short term.
Unpleasant side effects are often produced by chemotherapy treatment.Some cancer patients still manage to cope, thanks not only to themselves but also to their partner.Thus, the quality of life improves, and it is easier to cope with the treatment.The results of the conducted Mann-Whitney analysis show that there is a significantly higher level of distress in patients who noted the relationship with their partner as problematic (n=13, 5.8%) (4.7±3.9)compared to patients who did not report the presence of such a problem -94.2% (n=212) (3.8±3.0)(p>0.05).
Analyzing the data (by Chi square test), we found no relationship between demographic, clinicopathological characteristics and patients reporting relationship problems with their partner.Regression analysis did not demonstrate an association between high levels of distress and difficulty in relationships with the partner (OR 1.69,95% CI 0.53-5.3,p=0.3).During their treatment, some patients may find that they have difficulty carrying out certain activities that are part of their daily lives and interacting with other people without difficulty.Analyzing the questions related to family problems, almost all patients in the general group had no problems in their relationships with close friends (n=206, 91.6%).Some of the patients indicated that they encountered difficulties in their relationships with relatives (n=19, 8.4%).
The results show that there is a significantly lower level of distress in patients who stated that they have no problems communicating with their friends (3.6±3.0) in contrast to those who answered that relationships with close friends are problematic (5.2±3.2) (p= 0.036).The Fisher exact test showed a trend for an association between gender and patients reporting relationship problems with close friends (p=0.051).The nurse should focus on female patients who report a problem in their relationships with friends and relatives, discuss the problem with the attending physician, and discuss the possibility of referral to a psychologist for the necessary support.Regression analysis showed an association between high levels of distress and difficulty in relationships with close friends (OR 3.1, 95% CI 1.09-9.05,p=0.03).

DISCUSSION:
It is known that the diagnosis and the treatment of the oncological disease itself have more than a physical impact.Health care should be comprehensive and support the patient.The patient's social, spiritual and emotional needs should be assessed and discussed to help improve the quality of health care.Part of the patients could accept the diagnosis and chemotherapeutic treatment without serious emotional experiences, but there are also those who need psycho-social and emotional support to accept the disease.In cancer centers, the emphasis is often placed on health care, and interpersonal interaction may be neglected or limited.
The collected data show that the patients who noted the presence of difficulties in carrying out their professional activities or studies were significantly less (n=20, 9%) compared to those who indicated that they did not encounter problems related to work or school (n=205, 91%).Mann-Whitney analysis of the results showed significantly higher distress in patients who reported coping with work as a problem (4.8±3.4) compared to those who reported no problems with work (3.7±3.0)(p<0.05).It was interesting to find that there was a correlation between problematic relationships with children and the level of distress (p>0.05).Patients who confirmed problems in relationships with children were less in number (n=12, 5.3%) (4.0±3.3).They reported a higher level of distress than those who answered that they had no problems with relationships with children (n=213, 94.7%) (3.7±3.0).Although a smaller proportion of cancer patients indicate a problem in relationships, it is necessary for the nurse not to underestimate the problem

Fig. 1 .
Fig. 1.Relationship between levels of distress and child care in the family.

Fig. 3 .
Fig. 3. Distribution of patients according to the level of distress and the possibility of transportation to the medical facility.

Table 1 .
Distribution of patients according to the location of the primary tumor