Thai J Nurs Res factors influencing role adaptation cervical cancer

Thai Journal of Nursing Research
Vol. 6 No. 4 October - December 2002 ISSN-0859-7685
Factors Influencing Role Adaptation of Patients with Cervical Cancer
Receiving Radiation Therapy
Yupapin Sirapo-ngam, RN., DSN. Panwadee Putwatana, RN., D.Sc.
Luppana Kitrungroj, MNS. Virat Piratchavet, M.D.
Marital Developmental Tasks of Thai Spouses in Childrearing Families
Rutja Phuphaibul RN. , D.N.S. Arunsri Tachudhong RN. , M.S.
Chuanraudee Kongsaktrakul RN., M.P.H, M.N.S.
Self-regaining from loss of self-worth: A substantive theory of recovering
from depression of middle-aged Thai women
Acharaporn Seeherunwong, Tassana Boontong RN. Ed.D.,
Siriorn Sindhu RN., D.N.Sc., Tana Nilchaikovit M.D.
Chronic Dyspnea Self-Management of Thai Adults with COPD
Supaporn Duangpaeng RN, D.N.S. Payom Eusawas RN, Ph.D. Suchittra Laungamornlert RN, DNSc.
Saipin Gasemgitvatana RN, D.N.S. Wanapa Sritanyarat RN, Ph.D.
Exploring Ethical Dilemmas and Resolutions in Nursing Practice :
A Qualitative Study in Southern Thailand
Aranya Chaowalit RN. Ph.D. Urai Hatthakit RN. Ph.D. Tasanee Nasae RN. M.Ed.
Wandee Suttharangsee RN. Ph.D. Marilyn Parker RN. Ph.D.
Concept Analysis: Self-Efficacy
Wannipa Asawachaisuwikrom, Ph.D.
Spirituality: A Concept Analysis
Wanlapa Kunsongkeit RN. MNS.(Medical and Surgical Nursing)
Marilyn A. McCubbin RN. Ph.D. FAAN.

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Vol. 6 No. 4 ë October - December 2002 ISSN-0859-7685

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Vol. 6 No. 4 October - December 2002 ISSN-0859-7685
Content
163 Factors Influencing Role Adaptation of Patients with Cervical Cancer
Receiving Radiation Therapy
Yupapin Sirapo-ngam, RN., DSN. Panwadee Putwatana, RN., D.Sc. Luppana Kitrungroj, MNS.
Virat Piratchavet, M.D.
177 Marital Developmental Tasks of Thai Spouses in Childrearing Families
Rutja Phuphaibul RN. , D.N.S. Arunsri Tachudhong RN. , M.S.
Chuanraudee Kongsaktrakul RN., M.P.H, M.N.S.**
186 Self-regaining from loss of self-worth: A substantive theory of recovering
from depression of middle-aged Thai women
Acharaporn Seeherunwong, Tassana Boontong RN. Ed.D., Siriorn Sindhu RN., D.N.Sc.,
Tana Nilchaikovit M.D.
200 Chronic Dyspnea Self-Management of Thai Adults with COPD
Supaporn Duangpaeng RN, D.N.S. Payom Eusawas RN, Ph.D. Suchittra Laungamornlert RN, DNSc.
Saipin Gasemgitvatana RN, D.N.S. Wanapa Sritanyarat RN, Ph.D.
216 Exploring Ethical Dilemmas and Resolutions in Nursing Practice:
A Qualitative Study in Southern Thailand
Aranya Chaowalit RN. Ph.D. Urai Hatthakit RN. Ph.D. Tasanee Nasae RN. M.Ed.
Wandee Suttharangsee RN. Ph.D. Marilyn Parker RN. Ph.D.
231 Spirituality: A Concept Analysis
Wanlapa Kunsongkeit RN. MNS.(Medical and Surgical Nursing) Marilyn A. McCubbin RN. Ph.D. FAAN.
241 Concept Analysis: Self-Efficacy
Wannipa Asawachaisuwikrom, Ph.D.

Yupapin Sirapo-ngam et.al.
Vol. 6 No. 4 163
Factors Influencing Role Adaptation of Patients with Cervical
Cancer Receiving Radiation Therapy
Yupapin Sirapo-ngam, RN., DSN.* Panwadee Putwatana, RN., D.Sc.*
Luppana Kitrungroj, MNS.** Virat Piratchavet, M.D.***
* Associate Professor, Department of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University.
** Lecturer, Faculty of Nursing, Prince of Songkla University.
*** Assistant Professor, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University
Abstract: This descriptive study aimed to describe role adaptation and to ascertain
the predictive power of severity of side effects, self-esteem, social support, and
education on role adaptation of patients with cervical cancer receiving radiation
therapy. The Roy Adaptation Model was used as the conceptual framework for the
study. Eighty-six patients with cervical cancer receiving radiation therapy were
recruited from the outpatient radiotherapy unit of six hospitals in Bangkok during
February to June 2000. The inclusion criteria for the sample selected were women
who (1) were married and lived with their spouse, (2) had no treatment of radiation
or chemotherapy prior to participation in this study, (3) had been receiving radiation
therapy for at least a 3-week period, (4) were able to understand, and speak Thai,
and (5) agreed to participate in this study. There were five questionnaires used:
1) Demographic and Clinical Data Form, 2) Severity of Side Effects Questionnaire,
3) Rosenberg Self-Esteem Scale, 4) Personal Resource Questionnaire, and 5) Role
Adaptation Questionnaire.
It was found that patients with cervical cancer receiving radiation had a rather
good level of role adaptation. The stepwise multiple regression analysis revealed
that the combination of social support, self-esteem, and severity of side effects
accounted for 54.8% of the variance in role adaptation of patients with cervical
cancer receiving radiation. Education did not significantly account for the variance
in role adaptation. The result of this study was congruent with the role function
mode within the Roy Adaptation Model. Nurses should be concerned with the
influence of social support, self-esteem, and severity of side effects on patientsû
role adaptation and keep them in mind when caring of these patients. Future
intervention research on role adaptation of patients with cervical cancer receiving
radiation therapy should consider these factors.
Thai J Nurs Res 2002 ; 6(4) : 163-176
Keywords: role adaptation, cervical cancer, radiation therapy

Factors Influencing Role Adaptation of Patients with
Cervical Cancer Receiving Radiation Therapy
Thai J Nurs Res ë October - December 2002164
Background and Objectives
According to the annual statistical reports of
the National Cancer Institute of Thailand from
1994 to 1996,1
cervical cancer was the most
prevalent female cancer, with the highest
incidence in the middle-aged group (35-60 years).
Radiotherapy (RT) is one of the most common
treatment modalities for curing cancer of cervix
in its initial stages and for reducing complications
of the disease in the terminal stages2
(Einhorn,
1996). Although RT has many advantages, it can
produce many side effects that impact physical
and psychosocial health3-5
. Most women may also
undergo major role changes. These include
reducing and losing current role tasks and
integrating the sick role into their life.
Experiencing a major role change or transition to
a new role can be a stressful situation. Role
changing and the adoption of new roles require
the incorporation of new knowledge and
standards of behavior for role performances6
. There
is also a guarded effort and difficulty for these
patients to maintain other existing roles
effectively during the course of radiation. This is
important because these roles to which women
must adapt are often permanent and usually
include significant problems for the remainder of
their lives7
. These patients need much support from
others to adjust to effective role functioning.
Social support refers to the psychosocial and
tangible aid provided by significant others and/
or social networks8
. It is a major mean of assisting
patients to develop greater self-confidence and
feelings of autonomy and control in responding
to and modifying their environment. A person
receives various types of social support including
intimacy, opportunities for social integration,
opportunities for nurture and reassurance of worth.
An availability of informational, emotional, and
material supports is also important9
. Many studies
have confirmed the importance of social support
for chronically ill patients10-13
. Social support
enhances adaptive role performance which
improves physical recovery, psychological
well-being, and social functioning10-13
.
Level of education has also been associated
with role adaptation. Several studies have shown
the positive relationships between educational
achievement and role adaptation14-17
.
The objectives of this research were to
describe role adaptation of patients with cervical
cancer receiving radiation therapy and to
ascertain the predictive power of severity of side
effects, self-esteem, social support, and years of
formal education on role adaptation of patients
with cervical cancer receiving radiation therapy.
The Roy Adaptation Model18
was used as a
conceptual framework to study the severity of side
effects, self-esteem, social support, and education
on role adaptation of cervical cancer patients
receiving RT. This study focuses on roles of being
a wife, work (inside and outside the home), and
the sick role. The focal stimulus was the external
alteration produced by the radiation therapy. The
stimulus is acted upon by the coping mechanisms
through cognator and regulator subsystems. The
effects of the cognator and regulator activities are
observed in the four modes of adaptation. In this
study, the physiological, self-concept, and
interdependence modes were deducted from
empirical indicators that were severity of side
effects,self-esteem,andsocialsupport,respectively.
The behavioral responses of these three modes
may act as a pooled effect on the fourth mode,
the role function mode which reflects role
adaptation. The results of this study are important
for professional nurses to develop effective
nursing interventions that promote role
adaptation of patients receiving RT for cervical
cancer. Providing interventions focused on
support and resources can enhance role
performance and in doing so patients can achieve
social integrity.

Vol. 6 No. 4 165
Method
Subjects and Settings
The subjects were patients with cervical
cancer receiving radiation therapy who were
recruited from the outpatient radiotherapy
department of six tertiary care hospitals in
Bangkok. Data were collected in a five-month
period, February to June 2000. Purposive
sampling was used. The inclusion criteria were
women who: 1) were married and lived with their
spouse, 2) had no prior treatment with radiation
or chemotherapy, and 3) had been receiving
radiation (3,000 cGy), at least for a 3-week period.
Instruments
The instruments used for data collection are
composed of the 5 following parts:
1. Demographic and Clinical Data
Form. This included demographic and clinical
data obtained from interviews and medical records.
2. SeverityofSideEffectsQuestionnaire.
The severity of side effects questionnaire was
developed by the researcher which was based on
the Acute Toxicity Criteria of The Radiation
Therapy Oncology Group19
, and the literature
review. Only the frequent acute complications
associated with the major problems of these
patients were selected. Thus, the questionnaire
was comprised of 10 items, covering skin
reaction, food intake, nausea, vomiting, diarrhea,
dysuria, frequent urination, fatigue, and emotional
alteration. There were four descriptions of
severity of side effects ranging from normal/no
symptom = 1 to severe/abnormal symptom = 4.
Total scores ranged from 10 to 40. The higher the
scores, the greater the severity of side effects.
The alpha Cronbachûs coefficient of the severity
of side effects in this study was .73.
3. Self-Esteem Questionnaire. The
researchers used the Rosenberg Self-Esteem
(RSE) Scale20
for measuring patientsû
self-esteem. The scale contains 10 items; half
positive-score items and half negative-score items.
The scores of negative items are reversed. Each
item was indicated on a 4-point Likert-type scale
from strongly disagree to strongly agree. The RSE
Scale can yield a score from 10 to 40, with higher
scores indicating higher self-esteem. The internal
consistency of the RSE scale was tested in this
study and gained reliably adequate (Cronbachûs
alpha coefficients = .86).
4. Social Support Questionnaire. The
Personal Resource Questionnaire 85 (PRQ 85)-
Part II was used to measure the adequacy of the
individualûs perceived level of social support.
This instrument was developed and revised by
Brandt and Weinert9
. In this study, the researcher
used Soomlekûs questionnaire,21
which was
modified from the PRQ 85-Part II. It consists of
21 items on a 5 point-Likert scale including never
true = 1, rarely true = 2, somtimes true = 3, often
true = 4, and always true = 5. The total scores
ranged from 21-105. For the present study, the
Cronbachûs alpha coefficient of the PRQ 85-Part
II was .86.
5. Role Adaptation Questionnaire. The
original role adaptation questionnaire was
developed by Ounprasertpong22
for HIV positive
and AIDS patients based on role function mode
of the Roy Adaptation Model. This questionnaire
was used for assessing patientsû ability to
perform role behaviors. The questionnaire
emphasizes three sub-roles: wife role, work role,
and sick role. The Role Adaptation Questionnaire
was on a 5-point-Likert scale itemized as
follows: never perform =1, rarely perform = 2,
sometimes perform =3, often perform = 4, and
always perform =5. It contains 28 items including
20 positive items and 8 negative items. Total scores
ranged from 28-140. It was found that the
reliability as measured by Cronbachûs alpha
coefficient in this study was .80.

Protection of Human Subjects
The rights of the subjects were respected in
this study. Eligible subjects were individually
approached to participate in the study. The study
objectives, the data collection processes, expected
research outcomes, subject rights, the type of
questionnaires, length of time for completing the
questionnaires, and right to refuse to participate
in the study were explained. The subjects who
agreed to participate were assured that the data
would be kept confidential and reported as group
data.
Data Collection and Data Analysis
All eligible subjects who met the criteria were
approached and the protection of human subjectûs
protocol was explained as previously described.
The subjects, who volunteered to participate, read
and completed the questionnaires by themselves
in the following order: the Demographic and
Clinical Data Form, the Severity of Side Effects
Questionnaire, the Rosenberg Self-Esteem Scale,
the Personal Resource Questionnaire (PRQ-85
part II), and the Role Adaptation Questionnaire.
During this procedure, the investigator provided
more information and clarification when needed.
The researcher read the items on the questionnaires
to any participants experiencing difficulty in
reading. Reading the questionnaires by the
researcher was done to ninety percent of the
subjects.
The Statistical Package for Social Sciences
for Windows Program (SPSS/ FW) version 9.0
was used for data analysis. The predictive
powers of severity of side effects, self-esteem,
social support, and education on role adaptation
of patient with cervical cancer receiving
radiation therapy were analyzed using stepwise
multiple regression analysis.
Results
Eighty-six patients participated in the study.
The age of cervical cancer patients ranged from
25 to 65 with the mean age of 45.90 years. The
majority of the subjects (70.93%) were
middle-aged women (36-55 years). Most of the
subjects (65.11 %) completed formal primary
education. Approximately half of the subjects were
housewives and the rest worked outside the home.
Around thirty six percent of subjects had family
income of less than 5,000 baht per month; the
remainder had family income ranging from 5,001
to 90,000 baht. Nearly 47% of families had an
income that exceeded their expenses. Most of the
subjects (70.93%) were able to reimburse their
medical expenses from the government or from
their private insurance companies. The majority
of the subjects (77.91%) were diagnosed with
squamous cell carcinoma of the cervix and
approximately 59% were at stage II of the
disease. Nearly 70% of the subjects received doses
of radiation ranging from 3,001- 4,000 cGy for
16 to 20 days.
Based on the range of scores set up for the
interpretation, the mean scores of role adaptation
(role set score) were listed by each item from
highest mean score to lowest in Table 1. The mean
scores of role adaptation were 109.52 (S.D. =
11.77, min = 82, max = 132). It can be
interpreted that the subjects of this study had
levels of çRather Good Role Adaptationé.

Vol. 6 No. 4 167
Table 1.Means, standard deviations, and rank of role adaptation of cervical cancer patients
receiving radiation therapy (n= 86)
Role Adaptation Mean S.D. Rank
Regularly receiving radiation as the physician 4.95 .26 1
prescribed
Desiring to replace radiation with other alternative 4.90 .38 2
Treatments
Appropriately caring for radiated skin 4.83 .51 3
Taking preserved, spicy, or strong tasting foods 4.67 .69 4
Being discouraged and desiring to discontinue the 4.67 .79 5
treatment
Drinking adequate water 4.55 .90 6
Satisfied with my compliance with treatment 4.50 .72 7
regimens
Being irritated by fighting with husband 4.31 1.09 8
Wishing to a love and care for my husband 4.19 .94 9
Choosing healthy diet 4.15 .86 10
Regularly taking good perineal care 4.15 .87 11
Sleeping adequately 4.01 1.1 12
Talking and listening to husband 4.00 .89 13
Being anxious but do not apparently express 3.85 1.31 14
Observing abnormal symptoms by myself 3.77 1.03 15
Working intentionally 3.76 1.05 16
Being inert at work 3.73 .95 17
Consulting physicians/nurses concerning health 3.67 1.23 18
problems
Being proud of work. 3.66 .95 19
Exchanging experiences/ problems with other 3.57 1.15 20
similar patients
Being bored with the trip to the hospital daily 3.57 1.32 21
Being worried about insufficient family care 3.53 1.32 22
Seeking information concerning self-care practices 3.50 1.33 23
Taking care of family expense 3.48 1.83 24
Providing time and being responsible for work 3.30 .90 25
Improving work 3.16 1.02 26
Helping friends who have problems 2.86 1.18 27
Exercising 10-15 minute a day 2.23 1.41 28
Min = 82 , max = 132 total 109.52 11.77

As indicated in Table 2, the severity of side
effects had a mean score of 19.02 (S.D.= 4.53,
skewness = .37). It was found that the subjects
tended to perceive a low severity of side effects.
In contrary, self-esteem had a mean score of 34.30
(S.D. = 4.46, skewness = -1.13) and social
support had a mean score of 84.85 (S.D. = 11.81,
.45). So this indicated that the subjects
potentially have high self-esteem and perceived
high social support. Subjects tended to have a
low formal education with a mean of 6.06.
Table 2 Ranges, means, standard deviations, and skewness of the severity of side effects, self-
esteem, social support, and education (n= 86)
Variables Range Mean S.D. Skewness
Possible Actual
Range Range
Severity of side effects 10-40 10- 34 19.02 4.53 .37
Self-Esteem 10-40 18-40 34.30 4.46 -1.13
Social support 21-105 61-105 84.85 11.81 -.45
Education (year) ≥0 0-16 6.06 4.46 1.16
The correlations among predictor variables
and role adaptation were computed by using
Pearsonûs product moment correlation. The
correlation matrix among the studied variables is
presented in Table 3. The results revealed that
the role adaptation had a significant negative
correlation with the severity of side effects
(r = -. 43, p < .001). However, it is positively
correlated with self-esteem, and social support
(r = .52, p < .001; r = .68, p< .001) respectively.
There was no significant relationship between
role adaptation and education (r= .15, p > .05). In
addition, there were significantly low to
moderate relationships among predictors.
Severity of side effects was significantly and
negatively correlated with self-esteem and social
support (r = -.28, p < .01; r = -.33, p< .01).
Social support was significantly and positively
correlated with self-esteem and formal education
(r = .48, p < .001; r = .22, p < .05), respectively.
Table 3 The correlation matrix of the studied variables (n = 86)
Variables 1 2 3 4 5
1.Severity of side effects 1.00
2.Self-esteem -.28** 1.00
3.Social support -.33** .48*** 1.00
4.Education -.01 .09 .22* 1.00
5.Role adaptation -.43*** .52*** .68*** .15 1.00
*** p <.001, ** p < .01, * p < .05

Vol. 6 No. 4 169
Assumptions of regression analysis, which
involved considerations of residual scatter plots
were examined. The residual scatter plots indicated
that the assumptions of regression analysis were
met. All pairs of variables had linear correlation.
Multicollinearity, diagnosed by having correlations
among independent variables greater than .65, was
not found. All independent variables had low to
moderate correlations with one another (r = - .33
to .48). A Durbin-Watson value was 2.19, which
indicated that the regression error had no
autocorrelation23
.
As shown in Table 4, stepwise multiple
regression was used to analyze the predictive
power of severity of side effects, self-esteem,
social support, to role adaptation.
Social support, which had the highest
correlation with role adaptation, was first selected
in the regression equation. Social support
accounted for 46.4 % of the variance in role
adaptation (F change 1,84 = 72.66, p < .001).
This indicated that a one unit change in social
support will cause a 0.51 unit change in role
adaptation in the same direction (β = .51,
t = 5.89, p < .001). Next, self-esteem was
selected, which accounted for an additional 4.9 %
of the variance in role adaptation (F change1, 83
= 8.39, p < .01). This indicated that a one unit
change in self-esteem will cause a 0.22 unit change
in role adaptation in the same direction (β = .22,
t = 2.58, p < .05). Severity of side effects was
lastly selected into the analysis and accounted for
an additional 3.5% of the variance in role
adaptation (F change1, 82 = 6.30, p < .05). This
indicated that a one unit change in the severity of
side effects will cause a 0.20 unit change in role
adaptation in the opposite way (β = -.20,
t = -2.51, p < .05). The findings indicated that the
combination of social support, self-esteem, and
severity of side effects significantly accounted for
54.8% of the variance of role adaptation of
cervical cancer patients receiving radiation therapy
(overall F 3, 82 = 33.11, p < .001). Education did
not significantly account for the variance of role
adaptation. Therefore, the result of hypothesis
testing was partially supported.
Table 4 Stepwise multiple regression of role adaptation of cervical cancer patients receiving
radiation therapy (n = 86)
Predictors RSQ RSQ change F change β t
Social support .464 .464 72.66*** .51 5.89***
Self-Esteem .513 .049 8.39** .22 2.58*
Severity of .548 .035 6.30* -.20 -2.51*
side effects
(Overall F 3, 82 = 33.11, p < .001),*** p < .001 ** p <.01 * p < .05

Discussion
The mean score on role adaptation (role set)
was 109.52 which suggested that patients with
cervical cancer receiving radiation had levels of
çRather Good Role Adaptationû. The overall role
adaptation was viewed as the combination of
adaptation to three sub-roles including wife, work,
and sick roles. However, when considering the
ranking of mean scores by each individual item,
it was apparent that the seven highest mean scores
were in the sick role adaptation (Table 1). This
can be explained by the social mechanisms within
the role function mode of the RAM24
. It could be
reflected that the women with cervical cancer
receiving radiation may appraise and set the sick
role as the significant priority in setting behavior
priorities. The patients may have attempted to
integrate the sick role (new role) into their life,
while they had many current roles within their
role set (i.e., work and wife roles). When their
integration processes were challenged,
compensatory processes were activated. The
women formulated their effective role transition
in order to meet the goal of adaptation (i.e.maintain
their health and survival) by increasing their
adaptation level through cognator processes. They
simultaneously delegated their usual tasks to
family members or co-workers in order to comply
with radiation therapy schedules. Nevertheless,
they tended to maintain system balance between
roles of being sick, wife and work.
The findings from this study support
Soompoo and Tongtanunamûs studies17,25
of role
adaptation of patients with receiving cancer
treatments. In general, patients receiving cancer
treatments perform an effective role adaptation
or have a good sick role adaptation. However,
during the course of treatment, patientsû role
adaptation may change. As reported in two studies
conducted by Pittayapan26
and Ruankon27
, the
results showed that the outcomes of role function
and quality of life of patients with cervical
cancer in the third and the fifth week of radiation
were significantly lower than those outcomes prior
to radiation. These studies used a longitudinal
design that allowed changes to be collected over
time. Therefore, it is not surprising that the
findings of these previous studies are not
congruent with this present cross-sectional study.
Based on their sick role during radiation, the
patients should exercise 10-15 minutes a day. The
results showed that sixty-three percent of the
patients never or rarely exercised. Therefore, the
mean score of this item was the lowest (mean
= 2.23). It is possible that the patients might
believe that household activities were already good
exercise. In addition, being fatigued as a result of
the side effects of the treatment and daily
transportation diminished the desirability of
exercise. Graydon, et al.28
also reported that
patients who underwent cancer treatments were
often suggested to limit their activity and get plenty
of rest. In this study, nearly 50% of patients
indicated that they were reluctant to exercise
because of various reasons. For instance, they were
unsure if exercise might be risky for their health.
In addition, they rarely received advice from health
professionals in this respect. Accordingly,
performing exercise was reported to be the greatest
self-care deficit in cervical cancer patients
undergoing radiation5
.
Obviously, additional findings in this study
relate to sexual issues. Eight patients addressed
sexual and marital conflict. Specifically, they
mentioned the inability to have sexual relations
with their partner. Some patients said that they
could no longer have sex. However, this issue
was not able to be explored because it was
regarded as an embarrassing issue for the
subjects. Thus, the issues of exercise and sexual
relationships may add to the important problems
where patients tend to have an ineffective role
adaptation. Nurses, therefore, should be aware and
plan intervention to prevent ineffective role
behaviors.

Vol. 6 No. 4 171
The findings indicated that the combination
of social support, self-esteem, and severity of side
effects significantly accounted for 54.8% of the
variance of role adaptation is patients with
cervical cancer receiving radiation therapy. Among
predictors, social support was the strongest
variable influencing role adaptation. The subjects
reported that they received social support from
various resources such as a spouse or close friends
in several ways including intimate relationships
and attachment, and instrumental support. Small
social groups (i.e., a group of similar patients,
neighbors) were potential sources of companionship
and services. The work group may provide a sense
of belonging, competence, and usefulness for them
as well. Additionally, professional guidance is a
useful resource.
Taken together, it is not surprising that the
subjects who participated in this study have
adequate and compassionate social support that
consequently may (1) give them a sense of
self-esteem and personal efficacy, (2) enhance
cognitive processing required for effective
decision making and problem solving in stressful
situations, and (3) reduce negative moods. As a
result, social support would enhance cooperation
in engaging in effective role performance, and
consequently, role adaptation8,13,29-31
. These
findings are similar to that of the previous studies
in cancer patients receiving treatments12,25,32-34
The significant positive relationship between
social support and role adaptation supports the
conceptionwithintheRAM18
.Royûsconceptualization
of interdependency and two major stimuli
influencing role function, i.e., çaccess to facilitiesé
and çcooperation or collaborationé was viewed
as social support in this study. Thus, the findings
support the proposition of the RAM which stated
that there are interrelationships among adaptive
modes. Specifically, social support, as a factor
representing the interdependence mode, which
helps modify role behaviors in the role function
mode, influences role adaptation in this particular
group of patients.
Self-esteem was the second predictor
influencing role adaptation. There was a positive
relationship between self-esteem and role
adaptation. It can be explained that self-esteem is
an essential factor influencing behaviors leading
to personal effective functions. High self-esteem
empowers patients to be active participants in care,
helps the patients develop confidence in
interpersonal communication, and enhances the
potential for successful role performance. Thus,
patients with high self-esteem feel that they are
worth the time and effort needed to maintain and
improve health and eagerly take responsibility to
meet self-care needs. Conversely, the individual
with low self-esteem may be unable to make
self-care decisions and assume responsibility for
care outcomes35
. Obviously, during radiation,
about 50% of the sample received their wages
from actual employment. In addition, nearly half
of the workers (22 cases) reported that their rela-
tionship with friends and co-workers were as
usual. The work settings and the support that they
received in the work place or social environment
possibly produced a positive self-esteem and value
in these patients36-37
. In accordance with Uckanit38
,
Vichitvatee39
, and Yoswattana40
, self-esteem was
significantly and positively correlated with
self-care behavior and role adaptation in patients
with chronic diseases.
Severity of side effects was selected last to
enter in the regression equation, and had a
negative relationship to role adaptation. It may
be explained that the patients may have greater
or lesser symptom distress depending on the
perception of severity of side effects. According
to Roy and Andrews18
, physical and/or emotional
well-being affect the individualûs ability to fulfill
the role. In this study, all subjects were informed
about the disease, possible side effects, and how
to deal with the side effects. Moreover, they had
obtained information related to self-care
practices from several sources. They also had
developed strategies such as making appropriate

plans for their routine activities, seeking
information from similar cancer patients, or
asking the physician to treat the side effects that
would decrease the impact on their activities.
These findings are consistent with the previous
studies of Oberst and others4
and Irvine and
others41
. These two studies found that symptom
distress and fatigue were important factors
contributing to the self-care deficit of role
performance in cancer patients during
chemotherapy or radiation. Similar to the study of
Ruankon27
and Pongthavornkamol42
, the patients
with cervical cancer receiving radiation who had
greater complications of radiation had lower
quality of life and more disruptions of function
than those who had lesser complications. Also
Kawsasri43
found that perception of radiation
reactions could explain and accounted for 6.24%
of the variance in sick role adaptation of patients
with head and neck cancer who were receiving
radiation therapy.
Year of education was the only one predictor
that was not significantly correlated with role
adaptation. Possible explanations might be that a
high proportion of the sample had a low formal
education and received a high degree of support
services. Another possible reason could be that
most subjects in this present study were relatively
homogenous with respect to education. Around
72% of the patients had primary school certificates,
whereas only 12.79% of the patients had
vocational or undergraduate education.
With respect to receiving social support
services, patients who had difficulty in reading
still received information by listening to the
instructions verbatim from their children or other
family members. Moreover, the patients most
likely received indirect information by talking to
other patients, or learning through many other
sources (e.g., television, radio, internet document).
Receiving adequate information and increasing
their understanding regarding their illness and
treatments is helpful and may motivate them to
express adaptive behaviors. One study has shown
that patients who are informed about radiotherapy
procedures, possible side effects, and therapeutic
effectiveness do not experience disappointment,
fear, and anger3
. These findings are similar to the
study by Muhlenkamp and Sayle44
and by
Kaveevichai45
, which reported that education was
not correlated with positive health behaviors and
adaptation in healthy adults, and in patients with
mastectomy receiving chemotherapy. Education
had no correlation with quality of life in a study
of patients with cervical cancer receiving
radiation46
, and adaptation in patient with head
and neck receiving radiation32
. However, the
studies by Changphuang14
and Tongtanuman17
found that education was correlated with
adaptation or sick role adaptation in patients with
mastectomy receiving chemotherapy.
In conclusion, the combination of social
support, self-esteem, severity of side effects
accounted for 54.8% of the variance in role
adaptation of patients with cervical cancer
receiving radiation. The remaining 45.2 % other
influencing factors were not covered in this study
and need further investigation. Overall, the
research findings were congruent with the RAM
and contributed to the advancement of nursing
knowledge.
Recommendations
The results of this study apparently signify
the influences of social support, self-esteem, and
severity of side effects. Nurses should consider
the importance of these factors and keep them in
mind when caring of these patients. Enhancing
effective adaptation and preventing ineffective
adaptation should be the primary focus. In doing
so, factors influencing role adaptation should be
assessed followed by specific nursing interventions
based on the assessment. As the first leading
factor influencing role adaptation, social support

Vol. 6 No. 4 173
should be assessed and facilitated. The essential
element is the assessment of social support in
terms of resource availability (e.g., social networks,
financial or economic status, instrumental help),
psychological conditions (e.g., sense of love and
belonging, self worth), interpersonal relationships
(e.g., spouse, family members, friends), and
social activities. Interventions may include
recognizing, contacting, and inviting significant
others (i.e., spouse, children or relatives) to
participate in assisting role adaptation of the
patient during the course of radiation therapy.
Nurses should facilitate formal or informal group
support during treatment sessions as well as
provide substantial information necessary for
enhancing positive adaptation. Self-esteem,
another important influencing factor on role
adaptation, should be emphasized. Nurses should
begin with an assessment of self- esteem to
determine the level of the perception of self.
Enhancing positive self-esteem is valuable.
Nurses, therefore, should identify interventions
to promote self-esteem. Family and sexual
counseling should be provided to patients with
cervical cancer receiving radiation therapy when
needed. Although the severity of side effects was
shown to be less predictive on role adaptation in
this study, controlling the side effects is
necessary because it enables the patient to be
emotionally comfortable and be able to maintain
daily activities. Nurses should regularly assess
signs and symptoms indicating the side effects
of radiation regularly. Assessment of patientûs
knowledge regarding self-care practices to
overcome such side effects and to provide
required information is also essential. Moreover,
a special topic of continuing education relating to
role adaptation should be encouraged. This may
result in an increase in nursesû awareness of the
significance of this social aspect of the patients,
consequently improving the quality of nursing care.
This project was supported the research grant by
the China Medical Board.
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Rutja Phuphaibul et.al.
Vol. 6 No. 4 177
Marital Developmental Tasks of Thai Spouses in Childrearing
Families
Rutja Phuphaibul RN. , D.N.S.*Arunsri Tachudhong RN. , M.S.**
Chuanraudee Kongsaktrakul RN. , M.P.H, M.N.S.**
* Associate Professor, Pediatric Nursing Division, Ramathibodi Department and School of Nursing,
Mahidol University, Thailand.
** Assistant Professor * Pediatric Nursing Division, Ramathibodi Department and School of Nursing,
Mahidol University, Thailand.
Abstract: A comparative study was designed to compare the marital developmental
tasks of spouses in families with infants, preschoolers, schoolagers, and teenagers.
The sample consisted of 2,031 parents in the Bangkok metropolitan area whose
first child fell into one of these age groupings. The sample size of each age group
was approximately 500. Schools and hospitals were randomly selected to access
families with children of various age groups. A questionnaire developed by the
researchers was used in data collection. It was comprised of 2 parts , one of which
addressed family demographic data and the second addressed marital
developmental tasks. The results of the study revealed four major marital
developmental tasks including : a) financial tasks, b) family function delegation,
c) spousal relationship, and d) relationship with extended family members. In
comparing families with children in the various age groupings on marital
developmental tasks, the analysis of variance ( F=18.27, p<0.001) showed significant
differences. Post hoc analysis (Scheffeûs test) indicated significant differences
between families with preschoolers and all other age groupings, and between
families with schoolagers and families with infants. The families with infants had
the lowest score, and the highest score was in families with preschoolers. There
was a decreasing trend in families with schoolagers and further decline in the
families with adolescents.
Thai J Nurs Res 2002 ; 6(4) : 177-185
Keywords: spouse, family, development task,.

Rationale
The family provides an important
sociocultural context for individual members and
represents the basic social subsystem. The
structure of Thai families has changed gradually
as shown in the survey results of the National
Statistic Institution of Thailand. The findings
showed a declining family size as well as a
changing pattern of marital behavior1
Marital tasks remain essential in all couples
during the family development stages. Marital and
family relationship shows its impacts on mental
health problems of its members2-4
. Pasch and
Bradbury studied newly married couplesû
participation in 2 interaction tasks : a
problem-solving task in which spouses discussed
a marital conflict and a social support task in
which spouses discussed personal, nonmarital
difficulties. The couples who exhibited relatively
poor skills in both tasks were at particular risk
for marital dysfunction 2 years later5
. From
literature review on spousal marital tasks.
a number of studies were found that focused
on marital relationship in particular stages of
family life such as the beginning family, late
adulthood and retired couples, and couples who
have a chronically ill spouse5-7
. There was no
evidence of studies that examined the tasks of
spouses in different stages of family life.
Normally, Thai couples decided to have
offspring after 2-3 years of marriage. The
number of children desired has been between
1-2. Alterations in family roles from a couple
without children to a family with children of
different ages are expected to have an effect on
spousal relationships and role sharing.
Additionally, child rearing families at present have
more dual-career parents. This will certainly add
a burden on the nuclear family without child
rearing support from relatives. These couples will
have to share responsibilities in child care and
household work. Thus, family role performances
were expected to vary according to the family
developmental stages, that are usually defined by
the age of the first born child.
Family developmental tasks consist of 8:
1) Being an independent family after
marriage
2) Generating adequate income
3) Role sharing among members
4) Sexual satisfaction between couple
5) Communicating and relating among
members
6) Relating to family relatives
7) Interacting with organizations, groups,
and the community
8) Ability to provide care to offspring.
9) Having an appropriate life philosophy
Objectives of the study
The objectives of the study were to:
1. Examine the marital developmental tasks
of spouses in families with infants, preschoolers,
schoolagers, and adolescents.
2. Compare the marital developmental
tasks of spouses among families with infants,
preschoolers, schoolagers, and adolescents.
Hypotheses
There are significant differences among
marital developmental tasks of families with
infants, preschoolers, schoolagers, and adolescents.
Scope of the Study
The study was conducted among families
with firstborn children from newborn to 19 years
old living in Bangkok, whose children were
receiving educational, health care, and child care
services in various organizations.
Conceptual Framework
The conceptual framework of the study was
derived from the early work of Duvall in 1977 9
,
the researchersû pilot study in 1997, and a
literature review that addresses the changing

Vol. 6 No. 4 179
relationship within families according to the
period of the family life cycle. Family
developmental tasks 9 related to spousal
relationships at various child rearing periods
have been discussed in the literature. The spousal
roles or so called çmarital tasksé, may therefore,
be reconceptualized as çmarital developmental
tasksé as they would be expected to change as
the child grows older.
Four dimensions of marital developmental
tasks were derived from pilot study data collected
by of the researchers with 20 families as followed
1) Generating adequate family income,
including financial management within the family.
This dimension is referred to as çfinancial taské
2) Sharing family roles between spouses.
This dimension is referred as çfamily function
delegationé. Child care and housework flexibility
are important aspects of this dimension.
3) Maintaining good relationship between
the couple, including collaborative problem
solving, sharing feelings, sharing leisure time,
agreement on family planing, and sexual
satisfaction. This dimension is referred as çspousal
relationshipé.
4) Maintain good relationship between
the couple and relatives. This dimension is
referred to as çrelationship with extended family
membersé.
Definition of Terms
1. Marital developmental task performance
is referred as the activities of both husband and
wife in maintaining roles, functions, and optional
interaction between the couple, family members,
and relatives as measured by the questionnaire
developed by the researchers. The questionnaire
is based on Duvallûs Family Development Theory
and the results of a pilot study by the researcher
in 1997. A high score indicates good performance.
A low score indicates poor performance of marital
developmental tasks.
2. Family developmental stage signify
periods of the family life cycle which change over
time. The child-rearing families in this study were
divided into 4 groups according to the age of the
first child in the family.
2.1 Family with infant was the family
with the first born aged between
newborn and 2 and a half years old.
2.2 Family with preschooler was the
family with the firstborn aged
between 2 and a half years old and
6 years old.
2.3 Family with schoolager was the
between 6 and 13 years old.
2.4 Family with adolescent was the
between 13 and 19 years old.
Literature Review
Major concepts of family development theory
include the integration of family structural and
role functions during discrete time periods.
Family structure and function are derived from
structural functional theory10
. The interaction
between family members was viewed as a
semi-closed system which changes thoughout the
cycle of family life
Duvall described the essence of family
development in child-rearing periods as follows 9 :
Stage I : Beginning family. This stage starts
from marriage through the pregnancy of the
first child. During this period, the couple develop
their life as a couple and acquire skills in
understanding and adjusting to each other.
Family planning is essential during this period.
Stage II : Family with infant. The main
family developmental task here is focused on
adjusting to parenting roles and child rearing.
Stage III : Family with preschooler.
Preparation for school and socialization of the
preschool child are emphasized here. The couple
might plan to have the second child during this
period.

Stage IV : Family with schoolager. As the
child is able to help himself more, the family
focuses on providing educational opportunities and
promoting the childûs academic skill. Parentsû role
in socialization of the child and the influence of
their philosophy of life become more evident.
Stage V : Family with adolescent. Parents
need to become more flexible in the relationship
with their teen children. Teens are gradually
allowed to become more responsible for
themseleves. Communication between parents and
their child is the most essential component of this
period.
Four family developmental stages have been
selected for inclusion in this study (stagesII-V).
Family life cycle theory of Carter & McGoldrick
1988 emphasized the expansion and contraction
of family boundary and size, in addition to the
adjustment in family relationships during the
developmental course11
.
Families with marital problems have been
investigated in Thai couples revealing the need
for better understanding of the problem. A study
of familyûs problems in 115 couples from the
Psychiatric Outpatient Unit, found that most of
the clients who asked for assistance were female.
The most frequent psychiatric problems were
related to marital problem including depression
(27%), dysthymia (22.6%), and adaptive disorder
(19.1%), The main causes underlying these
problems were their spouse having affairs with
others (34.8%), psychological neglect (19.1%),
inability to love their spouse (10.4%), fear that
their spouse would have an affair (7.8%), their
spouse not sharing family roles and child care
(70%), their spouse being a drug addict (6.0%),
their spouse being a gambler (5.2%), problems
with relatives of their spouse (3.5%), sexual
problems (2.6%), family violence (1.7%),
financial problems (0.9%), and decision making
power (6.9%)12
.
Many studies suggested both positive and
adverse impact of the marital relationship on
physical and mental problems. Symptoms of
depression and sudden cardiac risk in cardiac
patients were adverse outcomes reported by Irvine
et al.in 19996
. A study in 2000 by Kung and Elkin
indicated that the patientûs level of marital
adjustment at termination of treatment of
depression and the extent of marital improvement
over the course of treatment significantly
predicted the treatment outcome at follow-up3
.
From the review of literature and pilot study,
it was evident that family problems derived
primarily from difficulties in the spouse
relationship dimension. The problems of role
sharing, finances, and relationship with relatives
were less intense. There has not been a study
comparing these tasks during various family stages
according to child rearing periods. Therefore, this
study was designed to explore the differences in
marital task performance among the different child
rearing stages.
Methodology
A descriptive design was used to examine
and compare the marital developmental tasks
among families with infants, preschoolers,
schoolagers, and adolescents.
Sample
The study sample was comprised of parents
in the Bangkok Metropolitan area with the
firstborn children in 4 specific age groups, living
in the same household. Only parents who were
literate and who agreed to participate were
included in the study sample. The data were
collected from 2,031 parents which included
514 family with infants, 511 families with
preschoolers, 506 families with schoolagers, and
500 families with adolescents. The table of
random numbers was used for sample selection.
Families with infants were selected from 10

Vol. 6 No. 4 181
Bangkok hospitals in the Pediatric Out Patient
and Obstetric Out Patient Departments. Families
with preschoolers were selected from 6 settings :
2 hospitals, 2 day care centers, and 2
kindergartens. Families with school age children
were selected from the following 10 settings :
5 government schools and 5 private schools.
Lastly, the adolescentsû families were selected
from 10 settings including 8 high schools and 2
University / Colleges.
Instruments
The instruments used in the study were
questionnaires developed by the researchers and
consisted of 1) Family demographic data and
2) Marital developmental tasks. Seven experts
reviewed the questionnaire for its content
validity. The Cronbachûs alpha was 0.82. The
marital developmental tasks questionnaire was
comprised of 22 items with 5 items on financial
tasks, 4 items for family function sharing on
delegation, 8 items on spouse relationship, and 5
items on relationship with relatives. The responses
were measured on a Likert scale with scores ranging
from 1-4 (from çneveré to çalways practiceé)
Results
The findings showed that the educational
level of the majority of the parents was below
10th
grade. The majority of the families with
infants (52.7%) were living in an extended
family structure. In families with preschoolers,
schoolagers, and adolescents the proportion of
extended family living situations decreased with
the increasing age of the first child (49.1%, 38.3%,
and 29.3%). (Here would be a good place to
comment about how the fact that the majority of
the families had more than one child was
accounted for in your interpretation of the
findings. Do you have data on what the ages of
the children were in families with more than one
child? I see this as a major confounding variable
since a family may have a child in any 2 of the
stages if there are 2 children or even 2 in one
stage. I realize that developmental theorists base
their ideas on the age of the first child, but this
makes your research findings difficult to interpret
with any confidence.) The majority of the
subjects were families with 1-2 children who lived
in urban areas. The mean scores in each of the 4
stages were as show in Table 1 and Figure 1.
Table 1 and Figure 1 display the variation of
subscores in families at different stages. It shows
that the marital task score was highest in the
preschool group (mean=68.14), while lower scores
were found in the school-age group (mean=66.17)
and the adolescent group (mean=65.20). The
lowest scores were found in the infant group
(mean=63.84)
Table 1 : Mean of the subscores and total scores of marital developmental task.
Tasks Stages (Families with) Total
Infant Preschool Schoolage adolescent Scores
1. Finance 15.30 18.07 18.16 18.12 63.84
2. Role / function 12.25 12.79 12.59 12.21 68.14
3. Spouse 24.33 24.01 22.61 22.23 66.17
Relationship
4. Relative 11.96 13.27 12.67 12.64 65.20
Relationship

The scores in each stage were then analyzed
in order to identify the differences between each
stage by comparing the mean differences using
ANOVA and Scheffeûs Test. The results in
Table 2 and 3 show that there were mean
differences among the 4 groups (F=18.30,
Figure 1 : Marital developmental Task Scores for families in 4 developmental stages
p < 0.001) and there were significant differences
in the means between infancy and preschool
periods, infant and schoolage periods, schoolage
and preschool periods ,and preschool and
adolescent periods (p < 0.05).
Table 2 : Comparison of mean of marital developmental task scores between families with
infants, preschoolers, schoolagers, and adolescents.
Source SS MS F p.
Between group 5,087.8 1,695.3 18.3 0.000
Within group 187,987.3 92.8
Total 193,073.0
Table 3 : Comparison of the mean score difference between each group using Scheffeûs test.
Stages Stages of Families
(Mean) Infant Adolescents Schoolage
Infant (63.84)
Adolescent (65.20) 1.36
Schoolage (66.17) 2.33* 0.97
Preschool(68.14) 4.30* 2.94* 1.97*
*P < 0.05

Vol. 6 No. 4 183
Discussion
The study findings revealed a variation in
marital task performance over the family life cycle
from infancy through adolescence. The lowest
marital task performance was found during the
infant period while the highest was during
preschool stage. After the preschool stage, the
score again decreased. Possible factors
contributing to decreased marital task
performance during the infant period include
the length of time that the couple has had to
develop their relationship and their need to adjust
to family life with child rearing. Although the
comparing spouse task according to the family
life cycle was limited, but when the tasks related
to financial task, family function delegation,
spousal relationship, and relationship with
extended family are not yet well adjusted.
Specially when the first child was an infant, the
overwhleming tasks caused the interaction
between distressed couple to be more negative.
It is notably that when measure marital
developmental tasks, the indicators are not only
the marital relationship, but including other
financial and relationship with extended family
and so on. Thus, it is not based only on symbolic
interaction framework like in many other
studies13
, but focused on the different tasks at
different developmental stages from developmental
perspectives. Family at different stages of
development focus on certain tasks that might as
well effect the spouse relationship. It is suggestive
that there should be further study to examine the
relationship between developmental tasks and
marital satisfaction. It will combined the family
perspectives from both the family structure and
functions and the interactionistic worldview.
The study showed that the Thai families with
adolescents show some difficulties in relation to
task performances as evidenced by having the
second lowest score on marital task performance.
There should be family counseling services
available to vulnerable families for adaptation
difficulties, particularly at the infant child rearing
and families with adolescents. Possible factors
contributing to decreased marital task performance
duringadolescenceincludedpotentialdisagreements
about the degree of independence permitted for
the adolescent in terms of sharing leisure time
with the family, communicating feelings and
collaborative problem solving. Findings from this
study suggest that family counseling might best
be targeted for families with infants and families
with adolescents. Further study is needed to
enhance understanding of the vulnerability to
family problems during different stages of family
development.
Reference
1. Limanond P. A Survey of Thai Families. The Institution
of Population Studies. Chulalonkorn University, 1996.
2. Gottman J. M. Psychology and the study of marital
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3. Kulik L. Marital relationship in late adulthood :
synchronous versus a synchronous couple. International
Journal of Aging and Human Development, 2001;
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4. Margolin G and Gordis E.B. The Effects of family and
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5. Pasch L.A. and Bradbury T.N. .Social support, conflict,
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6. Irvine J.I. Basinski A. Baker B. Jandciu S. Paquette
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9. Duvall E. Marriage and Family Development, 5th
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Vol. 6 No. 4 185
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Self-regaining from loss of self-worth: A substantive theory of recovering from
depression of middle-aged Thai women
Self-regaining from loss of self-worth: A substantive theory of
recovering from depression of middle-aged Thai women*
Acharaporn Seeherunwong**, Tassana Boontong***RN. Ed.D.,
Siriorn Sindhu***RN., D.N.Sc., Tana Nilchaikovit***M.D.
* A Dissertation for the Degree of Doctor of Nursing Science, Faculty of Graduate Studies, Mahidol University
** Assistant Professor, Department of Mental Health and Psychiatric Nursing, Faculty of Nursing, Mahidol University
*** Dissertation Committee
Abstract: Although, somatic treatments can effectively decrease depressive
symptoms, the opportunity of full recovery from depression in women is still
limited. This study aimed to generate a substantive theory that described and
explained how middle-aged Thai women, diagnosed with major depressive
disorder, experience and manage the problems in their lives and move from
depression toward recovery. The qualitative research method of grounded theory
was used. The participants consisted of 31 women who were diagnosed with major
depressive disorder in the three medical school hospitals in Bangkok. Building
rapport and in-depth interviews were the main methods for data collection.
Constant comparison and theoretical sensitivity were the basic analysis methods.
The substantive theory entitle çSelf-Regaining from Loss of Self-worth in
DepressiveMiddle-agedThaiwomenéwasdiscoveredfromrawdata.çSelf-Regainingé
has been found to be a basic social psychological process of recovering from
depression. This process consists of 3 phases - Causal condition of depression,
Learning about depression, and Recovering from depression. The first phase
explains how the women lose their self-worth until they recognize the deviance of
their life. The second phase consists of three overlapping sub-phases - Depression
self-management, Help seeking, and Contemplation about my self. These
sub-phases are strategies that contribute the women regained oneûs self. Finally,
the final phase involves Untying the knot and performing Self-growth of which is
the positive consequence in the process.
By better understanding the process of recovering from depression, nurses
and other healthcare providers can develop intervention to facilitate full recovery
from depression of middle-aged Thai women. The healthcare policy and education
policy can also be implicated with gender sensitivity. Future research also needs to
be carried out to derive a formal theory and to expand the scope of knowledge
about depression.
Thai J Nurs Res 2002 ; 6(4) : 186-199
Keyword: grounded theory study/ middle-aged Thai women/ recovering from
depression

Acharaporn Seeherunwong et.al.
Vol. 6 No. 4 187
Introduction
Women are more than twice as likely as men
to experience clinical depression both in the clinic
and in the community and in both developed and
developing countries.1-4
Also, the number of
out-patient Thai women in the year 1999-2000
were double the number of men.5
Moreover, one
in four women can expect to develop clinical
depression during her lifetime. Clinical depression
can occur in any women, regardless of age, race,
or income. In addition, it is serious enough to
lead to suicide.
Middle-aged women are one of the most at
risk for depression in a life span. It has been found
that 27% of the women aged 40 years and over in
Thailand suffer from depression.6
Another research
result shows that 13% of middle-aged out-patient
women with somatic symptoms at Rachaburi
hospital were detected for depression.7
In spite of an effort to decrease the numbers
of people with depression, various countries
demonstrates that major depression is a chronic,
recurrent condition. Between 15% and 20% of
patients have symptoms that persist for at least 2
years, and often these patients do not fully
recover from depressive episodes.8
Also, the
likelihood of an individual who has suffered one
episode of depression will experience a second
episode is probably greater than 40%.9-10
Furthermore, when a patient experiences a
second episode of depression, the probability that
he or she will develop a third episode is increased.9
Although, somatic treatment is a great success
for recovery from syndromes symptoms, it is not
successful for recovery from functional
symptoms.11-12
Therefore, the results indicate a
need for continued progress in developing
optimal treatment strategies for full remission and
to maintain long-term recovery.
Understanding strategies that the client
manages herself/himself toward recovery in their
culture and context will be an advantage to
complement the knowledge of health care
providers to help clients recover from depression.
Pluralistic management techniques to decrease the
cost of medical treatment which corresponds with
the special needs of women in Thai society is
also expected to be discovered. However, research
about depression in Thailand is very limited. This
Knowledge gap regarding recovering from
depression is needed to provide base knowledge
to understand and provide support for Thai women
with depression. As a result, Grounded Theory is
a suitable methodology to investigate the
phenomenon.
The purpose of the study was to generate a
substantive theory that described and explained
how middle-aged Thai women, diagnosed with
major depressive disorder, experience and manage
the problems in their lives and move from
depression towards recovery.
Methods
Grounded theory calls for an open approach
to data collection rather than adherence to
structured procedures. The purpose of data
collection is to get as wide as possible in the
effort to capture data that pertain to the
phenomenon of interest.13-14
In this study, a
variety of sources of data were obtained.
Middle-aged women who were diagnosed with
major depressive disorder were the primary
sources of data collection. In-depth interviews
were the main method for collecting data. The
participants who had delusion or hallucination
were excluded.
The final participants contained 31 women,
range of age from 35 to 63 years (mean=48,SD=8),
whose depression experiences varied widely,
ranging from two months to thirty years. More
than three-quarters of the participants were from
Ramathibodi Hospital (n=27). The rest were from
Siriraj Hospital and King Chulalongkorn
Memorial Hospital. Almost half of the participants

(n = 15) had a full recovery and 10 of them
perceived stable health. Almost all of the
participants were Buddhists (n = 27). The rest
were Christian and Islamic. The home province
of the participants was diverse; they came from
every part of Thailand. The majority of the
participants grew up in Bangkok (n = 16). Eight
participants grew up in the central part of
Thailand. However, 23 of them resided in Bangkok
and the suburbs during the time of data collection,
whereas eight of them resided in the provinces.
Moreover, one-quarters of educational background
for the participants were a bachelor degree (n=10).
Nine had a primary education. Three participants
did not attend any school and were unable to read
and write. The majority of the participants
(n = 10) were housewives. Nine of the
participants were government official and six of
them were employees.
Tape-recorded, open-ended, interactive
interviews were conducted with each participant
after the informed consent form was signed. The
interview began by asking for the symptoms of
the interview day and tracing back to the history
of their experience with depression from the first
moment they realized that something was wrong
with them, even if they did not initially define
the problem as depression. When asked, çPlease
tell me what it is like for you since the beginning
of your illnessé at the beginning of the interview,
five participants were encouraged to recollect their
experience from beginning toward recovery as
much as they could. The interview guide was
employed as appropriate during the interviews.
Gentle probes were also employed to enrich the
description of the experience and to maintain the
focus of the interview. Interview questions were
modified throughout the study according to the
emergence of the information to verify hypotheses
and concepts.
Evidently, discussion of issues related to
depression often involves recounting painful and
emotionally sensitive experiences. During the
interviews, several participants expressed suffered
feelings and cried. The interviews were paused
and opportunity was given to the participants to
express their feelings until they felt better.
Before the end of each interview, the researcher
made sure that the participants were in a peaceful
state of mind, observing their feelings and asked
for the feelings they were having at that moment.
The researcher and the participants parted only
when it was certain that they were emotionally
calm.
Each interview lasted at least 30 minutes and
most ran for well over 21
/2
hours. The average
was 112 minutes (S.D. = 48.85). The variation of
the time was due to the personality of the
participants as well as the richness and
complexity of information. For instance, some
participants had considerable self-observational
skills and analytical skills, so they could describe
their experiences in detail. Of the 25 participants,
two were interviewed twice to capture the
complexity and the richness of the participantsû
experiences and to test some hypotheses. For other
participants, the interview was conducted only
once because they did not come to see the doctor
on the appointment date and the researcher could
not communicate with them because they lived
in a remote province and they moved around, so
they could not remember their address.
Documents from technical literature and
non-technical literature served as the secondary
sources of data. Technical literature included
research publication and existing theories related
to experiences of depression, management, and
recovery from depression. Non-technical literature
included diaries, biographies, and other materials
related to depressive persons in the magazines, or
descriptive experience on a television talk-show
program. Medical records of the participants,
general observations made during interview
process and during home visits, and interviews of
psychiatrists were also employed as secondary
sources. The reason for the use of secondary

Acharaporn Seeherunwong et.al.
Vol. 6 No. 4 189
TyingtheKnot
TheCenterofMylife
NegativeAppraisalof
theCenterofMy
LifeûsReactions
Perceived
LossofSelf-Worth
UntyingtheKnot
-DiscoveringMySelf
-RedefinedMySelf&
theRelationWithOtherPeople
-RestartingMySelf
Self-Growth
Regaininga
NewPerson
Figure1:TheSubstantiveTheoryofSelf-RegainingfromLossofSelf-WorthofDepressiveMiddle-AgedThaiWomen.
ContemplationaboutMySelf
-Self-Awareness
-ReappraisalofReaction/Action
ofThoseWhoWeretheCenter
ofMyLife
PhaseI
Causalconditionofdepression
PhaseII
Learningaboutdepression
Symptomsof
Depression
DevastatedSelf
DepressionSelf-Management
-Tamjai(AcceptingSituation)
-DivertingMySelf
Recognitionof
Depression
Recognizing
Self-Deviance
HelpSeeking
-SeekingInformalHelp
-SeekingProfessionalHelp
PhaseIII
Recoveringfromdepression

sources was to increase theoretical sensitivity and
guide questioning for collecting and analyzing
data. As the study proceeded, data collection was
modified as necessary in order to focus on
concepts with relevance to the emerging theory.
The data analysis procedure in grounded
theory is the tool to generate new concepts and
theories from the data in the phenomenon of
interest. This analysis follow the Strauss and
Corbinûs procedure.12-13
The analysis procedure
began after the first interview was transcribed
verbatim until the writing of the findings was
finished, over one year and three months. Three
types of coding (open coding, axial coding, and
selective coding), constant comparison, theoretical
sampling, and memo writing were used as the
main strategies through the established theoretical
sensitivity of the researcher. In addition, the
trustworthiness of this study was established based
on the four criteria of credibility, transferability,
dependability, and confirmability. Formal
member check technique was employed by
having two fully recovered participants to verify
the developed theory. The peer debriefing
technique was also employed by having two
nursing lecturers and members of research
committee review analyzed data and findings.
Findings
The theoretical finding from grounded theory
analysis is the çTheory of Self-Regaining from
Loss of Self-Worth of Depressive Middle-Aged
Thai Womené as shown in Figure 1. This
developed theory consists of three phases
including : Phase I : Causal condition of
depression ; Phase II : Learning about depression ;
Phase III : Recovering from depression. Definition
of the constructs and concepts and their
relationships obtained from the study are proposed.
Phase I, ùCausal Condition of Depression:û
The findings reveal that ùTying the Knotû is a
basic social psychological problem. It is abstracted
from the process of interaction between ùThe
Center of My Lifeû and ùNegative Appraisal of
the Center of My Lifeûs Reactionû lead to a
consequence of ùPerceived Loss of Self-Worth.û
The more ùPerceived Center of My Life,û the
greater ùNegative Appraisal of the Center of My
Lifeûs Reaction.û The more ùNegative Appraisal
of the Center of My Lifeûs Reaction,û the greater
ùPerceived Loss of Self-Worth.û This consequence
leads to ùSymptoms of Depressionû abstracted from
ùDevastated Self;û that is, the response of perceived
Loss of Self-Worth,û until ùRecognition of
Depressionû abstracted from ùRecognizing
Self-Deviance.û Following, concepts in this phase
are described:
ùThe Center of My Lifeû referred to a
person or a group of people who were important,
and of great value for the women, as well as being
their source of pride. The centers of these womenûs
lives were not static and could be changed by
places, times, and events which occurred in their
lives. At the same time, the persons who were the
centers could come from many sources, depending
on which ones were considered more important
than the others. The participantsû perception of
ùThe Center of My Lifeû was based on Thai
social values. The person or the group might be
their children, husbands, or other people. As a
participant stated:
My children are my heart, I would die for
them, and whatever might happen to them,
I wish it would happen to me instead.
ùNegative Appraisal of the Center of My
Lifeûs Reactionsû referred to the appraisal of
participants who thought that they were treated
as unvalued people, had overloaded burdens,
and/or had sense of loss resulting from the
behavior of the centers of life. Participants
sacrificed their energy, ideas and intelligence to
their centers of life according to the social beliefs
and values to which they had been socialized. At
the same time, the participants also expected to

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