Dyadic effects of illness cognition and psychological distress among young and middle-aged couples with colorectal cancer: The mediating role of dyadic coping

Dyadic effects of illness cognition and psychological distress among young and middle-aged couples with colorectal cancer: The mediating role of dyadic coping | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dyadic effects of illness cognition and psychological distress among young and middle-aged couples with colorectal cancer: The mediating role of dyadic coping Qian Sun, Yuee Wen, Shuang Qin, Siyao Chen, Yan Lin, Junsheng Peng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3916812/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Young and middle-aged colorectal cancer patients, along with their spouses, face heightened vulnerability to psychological distress. The psychological distress of both patients and their partners may be influenced by illness cognition and dyadic coping. To explore the dyadic interplay of illness cognition, dyadic coping, and psychological distress, we aimed to validate dyadic coping as a mediator between illness cognition and psychological distress. Methods We conducted our study with 403 pairs of young and middle-aged patients with colorectal cancer and their partners, recruited from two tertiary hospital between May and September 2023. Participants completed questionnaires measuring illness cognition, dyadic coping and psychological distress. Results Our results revealed that both patients and spouses exhibited actor effects and partner effects regarding positive illness cognition/helplessness on dyadic coping. However, dyadic coping only had actor effects on psychological distress. Furthermore, we verified that dyadic coping mediates the link between positive illness cognition/helplessness and psychological distress. Conclusion These results offer fresh insights into the relationship of illness cognition, dyadic coping, and psychological distress at both individual and dyadic levels. They underscore the importance of promoting positive illness cognition and reducing helplessness in the context of cancer care. Healthcare providers play a crucial role in easing couples' psychological distress through the promotion of positive illness cognition and the reduction of feelings of helplessness. illness cognition dyadic coping psychological distress colorectal cancer couples Figures Figure 1 Figure 2 Figure 3 1. Introduction According to the tumor epidemiology data released by the World Health Organization, the global incidence of colorectal cancer exceeded 1.93 million in 2020, making it the third most prevalent malignant tumor. Additionally, approximately 930,000 deaths were attributed to this disease, positioning it as the second highest cause of mortality [ 1 ]. Projections indicate that the burden will rise by 60% by 2030, leading to the emergence of 2.2 million newly diagnosed cancer cases and 1.1 million cancer-related death [ 2 ]. Psychological distress, as outlined by the National Comprehensive Cancer Network (NCCN), refers to an emotional encounter triggered by a range of factors, encompassing psychological, social, and spiritual aspects, which are significantly unpleasant [ 3 ]. Acknowledging psychological distress as the sixth vital parameter, the International Psycho-Oncology Society (IPOS) underscores the significance of effectively addressing it in cancer patients as a means to ensure quality cancer care [ 4 ]. According to a study conducted by Dunn et al. [ 5 ], 32–44% of colorectal cancer patients experienced notable psychological distress within five years of their diagnosis. Furthermore, the stress endured by cancer patients can also affect their spouses, resulting in emotional disorders. The psychological burden placed on spouses can further exacerbate the fatigue and depression symptoms experienced by the cancer patients [ 6 ]. Among couples with rectal cancer, 55% of patients and 78.9% of partners experienced significant psychological distress at the time of diagnosis, which significantly affected their mental and sexual health within one year of diagnosis [ 7 ]. These results highlight the fact that couples affected by colorectal cancer are part of an emotional system, wherein psychological distress affects both individuals. The onset and medical management of colorectal cancer elevate the vulnerability of both partners to psychological distress. Hence, it is crucial to prioritize the psychological distress of couples dealing with colorectal cancer. Young and middle-aged individuals encounter distinctive obstacles in comparison to other age demographics, due to their substantial societal roles and responsibilities in various domains including family, academics, and social spheres. The diagnosis and treatment of cancer hinder their personal development and make it challenging to maintain normal social interactions. Additionally, colorectal cancer in this age group tends to have a more advanced clinical stage and a lower pathological grade, which is characterized by high malignancy and easy metastasis [ 8 ]. Young and middle-aged cancer patients, as well as their partners, display a greater tendency to actively pursue intimate relationships, unlike older patients. However, they frequently encounter challenges in adapting the dynamics of their marital relationship and express apprehensions regarding their interactions with their spouse and their sexual life [ 9 ]. As a consequence, they experience heightened psychological distress. Taking into account these factors, middle-aged and young patients with colorectal cancer, along with their spouses, face more obstacles compared to patients in other age groups, rendering them more vulnerable to psychological distress [ 10 ]. Psychological emotions are closely linked to quality of life, and the immune and neuroendocrine changes resulting from these emotions play a role in the pathological processes of cancer metastasis, recurrence, and treatment tolerance [ 11 ]. Additionally, colorectal cancer patients who experience psychological distress face obstacles in adopting a healthy lifestyle, which in turn diminishes their quality of life and adherence to treatment, ultimately increasing the risk of mortality [ 12 , 13 ]. Caregivers of cancer patients facing increased psychological distress also tend to undergo a decline in their overall quality of life [ 14 ]. Transactional Stress Theory and Interpersonal Interdependence Theory all emphasize that the illness constitutes a collective encounter encompassing both patients and their partners. Throughout the course of managing illness, there is a reciprocal relationship among illness cognition, coping mechanisms, and the resulting outcomes, including physical and mental well-being as well as overall quality of life. Extensive research has revealed that various factors such as illness cognition, dyadic coping, and other variables have a substantial influence on the psychological distress encountered by both cancer patients and their partners [ 15 ]. Illness cognition encompasses various cognitive psychological processes, such as assessment, interpretation, and comprehension, undertaken by individuals with a disease to evaluate their health condition and potential treatment options [ 16 ]. Research has indicated that breast cancer patients' positive perception of the illness has a lasting positive impact on their mental well-being and is closely associated with their happiness [ 17 ]. Conversely, negative beliefs about breast cancer among patients can hinder their coping mechanisms and impede their physical and mental recovery, leading to avoidance strategies, delayed medical intervention, and heightened psychological distress [ 18 ]. Spouses of cancer patients who possess negative thoughts and lack effective coping strategies often face heightened psychological distress and diminished psychosocial functioning [ 19 ]. The cognitive understanding of the illness by both the patients and their spouses can influence each other [ 19 ]. In light of the theoretical underpinnings and empirical studies reviewed, we posit that dyadic coping serves as a plausible mediator in the interplay between illness cognition and psychological distress within couples. This hypothesis forms the basis of our conceptual framework, as illustrated in Fig. 1 . 2. Methods 2.1 Participants We used a cross-sectional design for this study, selecting 479 couples with colorectal cancer through convenient sampling. The participants were recruited from two tertiary general hospitals in Guangzhou, China, between May and September 2023. The criteria for including couples were as follows: (a) patients who had received a colorectal cancer diagnosis; (b) aged 18–59 years; (c) informed about their cancer diagnosis, (d) proficient in reading and writing Chinese, and (e) willing to take part in the study. Couples with a history of mental illness, cognitive impairment, or other life-threatening conditions were excluded. This study obtained ethical approval from the Ethics Committee of Nursing School of Sun Yat-sen University and was performed in accordance with the Declaration of Helsinki. Prospective participants were identified via the electronic hospital information system. Upon contact, they were verified for eligibility criteria. After securing informed consent, both patients and their spouses were directed to independently complete the on-site survey, with subsequent quality checks of the completed questionnaires. Each participant required approximately 15–20 minutes to complete the questionnaires. 2.2 Measures 2.2.1 General Information We used a tailor-made questionnaire to gather data on demographics and factors related to cancer. The socio-demographic variables encompassed age, educational attainment, employment status, length of marriage, and per capita monthly income. Disease-related characteristics included time of diagnosis, tumor site and presence or absence of stoma. 2.2.2 Illness Cognition Questionnaire The ICQ developed by Evers et al. [ 20 ] assesses patients' psycho-behavioral perception of the stress and aversive aspects related to their illness. Han et al. [ 21 ] introduced and sinicized ICQ in 2018. The Chinese version of ICQ consists of 18 items in three dimensions, including helplessness, acceptance and perceived benefits, with 6 items in each dimension. We employed a Likert scale, spanning from 1 (completely disagree) to 4 (completely agree), to assess responses. The Chinese version of ICQ exhibited strong internal consistency, with Cronbach's alpha coefficients ranging from 0.86 to 0.88 [ 21 ]. Specifically, we utilized the acceptance and perceived benefit subscales to measure positive illness cognition, with a possible score range of 12 to 48. The positive ICQ subscale exhibited robust internal consistency, as reflected by a Cronbach's alpha of 0.81. The text of the questions was adapted to the spouse version of ICQ to make it appropriate for the spouses of patients. For example, “my illness” in the original questionnaire was changed to “my spouses’ illness”. This study used the patient version and spouse version of ICQ to measure the illness cognition of colorectal cancer patients and spouses, respectively. 2.2.3 Dyadic Coping Inventory The DCI was utilized to evaluate the collaborative coping strategies employed by partners in response to shared stressors [ 22 ]. The DCI comprises 37 items, encompassing six dimensions: stress communication (8 items), supportive dyadic coping (10 items), delegated dyadic coping (4 items), negative dyadic coping (8 items), common dyadic coping (5 items), and two general dyadic coping items (items 36 and 37) [ 23 ]. Responses are rated on a 5-point scale, where 1 indicates “very rarely”, and 5 corresponds to “very often”. Out of the 37 items, items 7, 10, 11, 15, 22, 25, 26, and 27 are designated as reverse scoring items. These items are evaluated differently to provide a more accurate assessment. Additionally, items 36 and 37 are specifically used to evaluate self-rated satisfaction using dyadic strategies and are not included in the overall score calculation. The total scores on the DCI ranged from 37 to 175, with higher scores indicating more effective dyadic coping levels. The DCI demonstrated strong internal consistency, as reflected in a Cronbach's α coefficient of 0.92 [ 23 ]. 2.2.4 Kessler psychological distress scale-10 The K10 developed by Kessler et al. [ 24 ] in 1992, measures the frequency of non-specific mental health symptoms such as anxiety and stress levels experienced by patients in the past 4 weeks, including fatigue, tension, helplessness, restlessness, depression, disinterest, and worthlessness. The scale employs a 5-point rating system, with responses ranging from "almost never" to "all the time". The total score, ranging from 10 to 50, reflects the level of psychological distress, with a higher score indicating a greater degree of distress. The K10 distress levels were classified into four categories: no psychological distress (10–15 points), mild psychological distress (16–21 points), moderate psychological distress (22–29 points), and severe psychological distress (30–50 points). Previous research has reported Cronbach's α coefficients for this scale ranging from 0.76 to 0.92 [ 25 ]. 2.3 Sample size We used a simplified method to estimate the sample size, which involved considering 5–10 times the quantity of study variables [ 26 ]. Given that our study had 17 variables, this approach recommended a sample size range of 85–170 patients. To account for potential attrition, we factored in a 20% attrition rate, leading to a minimum required sample size of 107 couples. 2.4 Statistical analyses We have summarized the sample characteristics using means, standard deviations (SDs), frequencies, and percentages. Pearson’s correlation analyses were employed to examine associations among continuous variables (illness cognition, dyadic coping and psychological distress). We employed Amos 28 software to conduct a series of Actor-Partner Independence Models (APIMs) to examine the impact of illness cognition and dyadic coping on psychological distress. This examination encompassed effects on individuals (actor effects) and their respective spouses (partner effects). Initially, we established fully saturated models [ 27 ], refining them by eliminating non-significant paths to derive an unsaturated model. We evaluated the fit of the unsaturated model using various indices, including the Comparative Fit Index (CFI > 0.90), Normed Fit Index (NFI > 0.90), Root Mean Square Error of Approximation (RMSEA < 0.05 indicating a good fit; RMSEA < 0.08 considered acceptable), and the χ 2 /df ratio (χ 2 /df < 5) [ 28 ]. 3. Results 3.1 Sample characteristics Of all the 479 couples with colorectal cancer who met the inclusion criteria, 45 (9.4%) declined because of having no time or interest, and 31 patients (6.5%) withdrew before completing the survey. In total, 403 dyads effectively completed these questionnaires (84.1%). The median age of colorectal cancer patients and their partners was 49.0 years (IQR = 14.00) and 48.0 years (IQR = 13.00), respectively. The majority of couples had been married over 20 years (n = 257, 63.8%). Over half of the sample were employed, and 53.1% of them had received a colorectal cancer diagnosis within the past 6 months. Further demographic details can be found in Table 1 . Table 1 Characteristics of patients and spouses (n = 403 dyads) Category Patient Partner n % n % Age median (IQR) 49.00 (14.00) 48.00 (13.00) Gender Male 251 62.3 152 37.7 Female 152 37.7 251 62.3 Education level Elementary school or below 37 9.2 38 9.4 Junior high school 129 32.0 121 30.0 High school/technical secondary school 72 17.9 89 22.1 University or college education 154 38.2 147 36.5 Master degree or above 11 2.7 8 2.0 Employment Pension/early retirement 41 10.2 44 10.9 Employed 268 66.5 290 72.0 Unemployed 94 23.3 69 17.1 Duration of marriage 8000 91 22.6 Cancer type Colon cancer 177 43.9 Rectal cancer 226 56.1 Tumor stage I 23 5.8 II 55 13.6 III 190 47.1 IV 135 33.5 Diagnosis time Within 3 months 138 34.2 3–6 months 76 18.9 6–12 months 72 17.9 1–3 years 77 19.1 Over 3 years 40 9.9 Stoma Yes 137 34.0 No 266 66.0 3.2 Analysis outlining the characteristics of the study variables The mean scores for positive illness cognition, hopeless, dyadic coping and psychological distress of patients were 32.59 (7.20), 13.80 (4.05), 112.66 (19.64) and 21.04 (7.49), respectively. And the mean scores for positive illness cognition, hopeless, dyadic coping and psychological distress of spouses were 33.73 (7.76), 12.79 (4.23), 113.20 (19.00) and 21.41 (7.78), respectively. The scores for positive illness cognition, hopelessness, dyadic coping, and psychological distress exhibited significant correlations between patients and their spouses. Specifically, positive illness cognition, hopelessness, and dyadic coping significantly influenced the psychological distress experienced by patients themselves. Likewise, among the spouses, positive illness cognition, hopelessness, and dyadic coping showed significant associations with their own levels of psychological distress, as detailed in Table 2 . Additionally, patients' psychological distress displayed significant correlations with their spouses' positive illness cognition, hopelessness, and dyadic coping, while spouses' psychological distress was significantly associated with patients' positive illness cognition, hopelessness, and dyadic coping, as indicated in Appendix Table S1 . Table 2 Within-Person Bivariate Correlations between Illness cognition, Dyadic coping and Psychological distress Variable Positive illness cognition Hopeless Dyadic coping Psychological distress Positive illness cognition -.19** .48** -.35** Hopeless -.32** -.26** .57** Dyadic coping .50** -.34** -.35** Psychological distress -.49** .56** -.38** Note. Patients’ correlates are on lower diagonal and shaded in light grey and spouses correlations on upper diagonal in darker grey. *p<.05, **p<.01, ***p<.001 3.3 Dyadic effects of positive illness cognition and dyadic coping in psychological distress The standardized estimates for the Actor-Partner Independence Mediation Model (APIMeM) involving positive illness cognition, dyadic coping, and psychological distress can be found in Appendix Table S2 and Model 1 (Fig. 2 ). In the course of this analysis, six noteworthy actor effects and two effects pertaining to partners were identified. Moreover, four significant mediating effects were identified within this model. Specifically, the dyadic coping exhibited by both patients and spouses acted as a regulatory factor in mediating the relationship between patients' positive illness cognition and their psychological distress, spouses’ positive illness cognition and their psychological distress, patients’ positive illness cognition and their spouses’ psychological distress, as well as spouses’ positive illness cognition and patients’ psychological distress. Specific parameter details are provided in Appendix Table S2. The initial model was presented as a saturated one, limiting our ability to assess model fit with the sample data. To assess the congruence of our proposed hypothesis model with the sample data, we systematically excluded pathways that demonstrated statistical insignificance [ 29 ]. These pathways included positive illness cognition (patient)→psychological distress (spouse), dyadic coping (patient)→psychological distress (spouse), positive illness cognition (spouse)→psychological distress (patient), and dyadic coping (spouse)→psychological distress (patient). Ultimately, we arrived at an unsaturated model 1 with favorable fit indices (RMSEA = 0.069, CFI = 0.980, NFI = 0.971, CMIN = 38.077, DF = 13, CMIN/DF = 2.929). 3.4 Dyadic effects of hopeless and dyadic coping in psychological distress Standardized estimates for the APIMeM of hopeless, dyadic coping and psychological distress are found in Appendix Table S2 and model 2 (Fig. 3 ). Six notable actor effects and two effects associated with partners were identified. Moreover, we identified four noteworthy mediation effects: the dyadic coping of both patients and spouses played a regulating role in the connections between patients' hopelessness and psychological distress, spouses' hopelessness and psychological distress, patients' hopelessness and spouses' psychological distress, as well as spouses' hopelessness and patients' psychological distress. Specific parameters can be found in Appendix Table S2. After removing insignificant pathways (hopelessness (patient)→psychological distress (spouse), hopelessness (spouse)→psychological distress (patient), dyadic coping (patient)→psychological distress (spouse), dyadic coping (spouse)→psychological distress (patient)), the fit indices of Model 2 indicated a strong fit (RMSEA = 0.020, CFI = 0.999, NFI = 0.993, CMIN = 4.658, DF = 4, CMIN/DF = 1.164). 4. Discussion In this study, we applied the dyadic approach of the APIMeM to examine the intricate dynamics involving dyadic coping, illness cognition, and psychological distress in colorectal cancer couples who fall into the young and middle-aged demographic categories. We identified substantial actor effects, indicating that positive illness cognition exhibited a strong positive correlation with an individual's own psychological distress in couples. This finding was in accordance with prior research, consistently indicating that positive illness cognition among cancer patients significantly predicts an increase in psychological distress [ 30 ]. A meta-analysis revealed that patients who believed their disease was incurable and uncontrollable faced more physical, emotional, and social challenges compared to those who believed their disease was treatable and controllable [ 31 ]. Previous study has indicated that patients' perception of their illness influences their ability to cope and adapt, including their medical treatment behavior, adherence to treatment, and emotional well-being [ 32 ]. Consequently, this perception indirectly or directly impacts the disease prognosis, patient's quality of life, and social functioning [ 33 ]. Dempster et al. [ 30 ] undertook research into the psychological distress experienced by family caregivers of esophageal cancer patients and revealed a noteworthy association between the caregivers' illness cognition and their psychological distress. Second, we found that young and middle-aged colorectal cancer who reported better dyadic coping demonstrated less psychological distress and the same results were found in their spouses. Chen et al. [ 34 ] conducted an extensive literature review, examining the connection between dyadic coping and outcomes in couples coping with cancer. In the comprehensive review of 28 studies, positive factors like communication, supportive dyadic coping, delegated dyadic coping, and common dyadic coping were linked to stronger marriages, reduced stress, and improved mental health for couples [ 34 ]. Conversely, negative dyadic coping and engagement in protective buffering were associated with reduced relationship satisfaction, lower quality of life, and an increase in depressive symptoms. Regan et al. [ 15 ] assessed the psychological distress of prostate cancer couples using the Hospital Anxiety and Depression Scale. The results indicated that for patients, depression was related to their own supportive dyadic coping, spouses' negative coping, and common coping. For spouses, spouses’ anxiety was correlated with their own and partner's negative dyadic coping, but depression was not correlated with dyadic coping. Additionally, Lim et al. [ 35 ] highlighted the interaction between coping and psychological distress of couples with cancer. This underscores the bidirectional influence of anxiety and depression between patients and their spouses, emphasizing the significance of comprehensive coping strategies tailored to benefit the mental health of both individuals. Third, our findings indicated that the dyadic coping of patients and their spouses was influenced by their individual and their partners' positive illness cognition. A study conducted by Checton et al [ 36 ]. revealed that patients' illness cognition could have a negative impact on their dyadic coping. A systematic review found increased engagement in avoidance coping was linked to an increased perception of the severity of cancer and a reduced understanding of illness coherence [ 37 ]. Conversely, individuals possessing a heightened sense of personal control are more inclined to actively employ coping strategies [ 37 ]. Therefore, recognizing the disease in a positive light is crucial for the coping mechanisms of young and middle-aged couples with colorectal cancer. Furthermore, our findings suggest that couples using dyadic coping strategies played a vital role in mediating the link between positive illness cognition and psychological distress. Additionally, these coping strategies were shown to mediate the connection between patients' positive illness cognition and psychological distress experienced by their spouses. It is evident that individuals diagnosed with cancer and their spousal caregivers share comparable emotional reactions when confronted with the challenges of a cancer diagnosis and treatment, including distress, anxiety, depression, fear, uncertainty, and denial [ 38 ]. A study conducted on lung cancer patients and found that the way patients perceive their illness can directly impact their psychosocial adaptation during chemotherapy [ 39 ]. The study also found that coping strategies play a crucial role in this relationship. Patients who hold negative perceptions of their condition often adopt different coping mechanisms to improve their mental well-being and adjust to the challenges associated with the disease. Conversely, embracing positive coping styles can result in a more favorable perception of cancer and enhance overall psychosocial adaptation. On the other hand, relying on negative coping strategies can diminish positive perceptions of cancer and hinder recovery outcomes. Our research findings shed light on the correlation between helplessness, dyadic coping, and psychological distress among young and middle-aged couples dealing with colorectal cancer. A study conducted by Lyons et al. [ 40 ]. revealed that the evaluation and coping strategies of couples facing lung cancer have a substantial impact on the psychological well-being of both individuals, even when accounting for situational factors. Model 2 examines the negative effects of helplessness on self-reported psychological distress in couples. It hinders the development of dyadic coping and weakens the spouse's psychological well-being. Valentine et al. [ 39 ] studied the relationship between illness cognition, coping, and psychosocial adaptation in lung cancer patients. And the findings indicate that illness cognition directly impacts the psychosocial adaptive ability of patients undergoing chemotherapy, and this impact can be further enhanced through the adoption of coping strategies. Patients with more adverse perceptions typically employ various coping strategies to better adapt to the challenges brought on by the disease. Therefore, addressing helplessness in young and middle-aged couples facing colorectal cancer is crucial. Implementing positive psychology techniques is recommended to alleviate psychological distress in both patients and their partners. 4.1 Study limitations Our study has certain limitations that warrant acknowledgment. Firstly, despite the relatively substantial sample size, our study involved young and middle-aged colorectal cancer survivors, along with their spouses, recruited from two medical centers, which may not accurately represent a wider population. Secondly, due to the reliance on self-reported data, it is essential to interpret the findings with caution. Thirdly, this cross-sectional design hinders the capability to investigate the dynamic evolution of psychological distress and establish causal relationships. Longitudinal studies are needed to better understand the psychological distress in both partners throughout the journey from the initial cancer diagnosis to recovery. 4.2 Implications for Practice Our findings indicate that interventions aimed at reducing psychological distress in young and middle-aged couples with colorectal cancer should take into account both individuals within the couple. It is important to promote positive illness cognition by encouraging acceptance and perceived benefits. Additionally, to enhance dyadic coping, it is recommended to foster positive communication while simultaneously diminishing blame and avoidance. Fostering positive illness cognition was not only beneficial to one’s own dyadic coping but also beneficial to that of his/her spouse. Furthermore, our study found that dyadic coping plays a mediating role between positive illness cognition/helplessness and psychological distress in colorectal cancer couples. Therefore, these approaches can be utilized to develop interventions that enhance dyadic coping, ultimately leading to reduced couples’ psychological distress. 5. Conclusions Our findings underscored that in couples, positive illness cognition and dyadic coping were positive predictors of psychological distress, while helplessness served as a negative predictor. These mediation results suggest the central approach for mitigating psychological distress involves enhancing positive illness cognition, reducing helplessness, and strengthening dyadic coping. Declarations Ethical approval The study has been approved by the Ethics Committee of Nursing School of Sun Yat-sen University (No. L2023SYSU-HL-004) and performed in accordance with the Declaration of Helsinki. Competing interests I declare that the authors have no competing interests as defined by Springer, or other interests that might be perceived to influence the results and/or discussion reported in this paper. FUNDING STATEMENT No external funding was used for this study. Author Contribution All listed authors (A. B. C. D. E.) meet the authorship criteria and that all authors are in agreement with the content of the manuscript. All the authors substantially contributed to the (1) design of the study, (2) data extraction, data analysis and interpretation, (3) drafting of the article and (4) approval the final version for publication. Acknowledgements This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References Sung H, Ferlay J, Siegel RL et al (2021) Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 71(3):209-249. https://doi.org/10.3322/caac.21660 Arnold M, Sierra MS, Laversanne M, Soerjomataram I, Jemal A, Bray F (2017) Global patterns and trends in colorectal cancer incidence and mortality. 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J Am Stat Assoc 101(2). https://doi.org/10.1002/0470013192.bsa655 Orth U (2013) How large are actor and partner effects of personality on relationship satisfaction? The importance of controlling for shared method variance. Pers Soc Psychol Bull 39(10):1359-1372. https://doi.org/10.1177/0146167213492429 Dempster M, McCorry NK, Brennan E, Donnelly M, Murray LJ, Johnston BT (2011) Psychological distress among family carers of oesophageal cancer survivors: the role of illness cognitions and coping. Psychooncology 20(7):698-705. https://doi.org/10.1002/pon.1760 Hagger M, Orbell S (2003) A Meta-Analytic Review of the Common-Sense Model of Illness Representations. Psychol Health 18(2):141-184. https://doi.org/10.1037/bul0000118 Richters A, Derks J, Husson O et al (2015) Effect of surgical margin status after radical prostatectomy on health-related quality of life and illness perception in patients with prostate cancer. Urol Oncol Semin Ori 33(1):16.e19-16.e15. https://doi.org/10.1016/j.urolonc.2014.10.006 Postolica R, Iorga M, Petrariu FD, Azoicai D (2017) Cognitive-Behavioral Coping, Illness Perception, and Family Adaptability in Oncological Patients with a Family History of Cancer. Biomed Res Int 8104397. https://doi.org/10.1155/2017/8104397 Chen M, Gong J, Cao Q, Luo X, Li J, Li Q (2021) A literature review of the relationship between dyadic coping and dyadic outcomes in cancer couples. Eur J Oncol Nurs 54:102035. https://doi.org/10.1016/j.ejon.2021.102035 Lim JW, Shon EJ, Paek M, Daly B (2014) The dyadic effects of coping and resilience on psychological distress for cancer survivor couples. Support Care Cancer 22:3209-3217. https://doi.org/10.1007/s00520-014-2334-9 Checton MG, Magsamen-Conrad K, Venetis MK, Greene K (2015) A dyadic approach: applying a developmental-conceptual model to couples coping with chronic illness. Health Educ Behav 42:257-267. https://doi.org/10.1177/1090198114557121 Richardson EM, Schüz N, Sanderson K, Scott JL, Schüz B (2017) Illness representations, coping, and illness outcomes in people with cancer: a systematic review and meta-analysis. Psychooncology 26:724-737. https://doi.org/10.1002/pon.4213 Goldzweig G, Schapira L, Baider L, Jacobs JM, Andritsch E, Rottenberg Y (2019) Who will care for the caregiver? Distress and depression among spousal caregivers of older patients undergoing treatment for cancer. Support Care Cancer 27:4221-4227. https://doi.org/10.1007/s00520-019-04711-6 Valentine TR, Presley CJ, Carbone DP, Shields PG, Andersen BL (2022) Illness perception profiles and psychological and physical symptoms in newly diagnosed advanced non-small cell lung cancer. Health Psychol 41:379-388. https://doi.org/10.1037/hea0001192 Lyons KS, Miller LM, McCarthy MJ (2016) The Roles of Dyadic Appraisal and Coping in Couples With Lung Cancer. J Fam Nurs 22:493-514. https://doi.org/10.1177/1074840716675976 Additional Declarations No competing interests reported. Supplementary Files AppendixTableS1S2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3916812","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":275793902,"identity":"fa499d72-5b6e-4d94-8743-c6d2bbfee159","order_by":0,"name":"Qian Sun","email":"","orcid":"","institution":"Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Qian","middleName":"","lastName":"Sun","suffix":""},{"id":275793903,"identity":"1498e239-1689-4cb8-982d-c4e7811b4d90","order_by":1,"name":"Yuee Wen","email":"","orcid":"","institution":"Sixth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Yuee","middleName":"","lastName":"Wen","suffix":""},{"id":275793904,"identity":"13f5e7bb-1d90-481b-b76f-7da2d753ba03","order_by":2,"name":"Shuang Qin","email":"","orcid":"","institution":"Sixth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Shuang","middleName":"","lastName":"Qin","suffix":""},{"id":275793905,"identity":"54bbbb76-b4d5-45cd-a024-cdf876f80ba7","order_by":3,"name":"Siyao Chen","email":"","orcid":"","institution":"Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Siyao","middleName":"","lastName":"Chen","suffix":""},{"id":275793906,"identity":"f8585803-c550-4a21-84d2-a2256ef2c928","order_by":4,"name":"Yan Lin","email":"","orcid":"","institution":"Sixth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Lin","suffix":""},{"id":275793907,"identity":"264d7b9a-eef5-49d7-b3c4-7539aa05be53","order_by":5,"name":"Junsheng Peng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYBACNobDBx984LGp52dvPkCcFj7GY8mGM2TSEiR7jiUQp0WO+YyaNI/N4QSDGzkGRDqM7QyzAU8Ocx7DmTMfb7xhsJPTbSCkhefswQcSZ9iKGdt7N1vOYUg2NjtASIvEuWQDwx4exmaes9ukeRgOJG4jqEX+jZlE4j8JxjaJnGdEamE4YyZxgMcgsUcih41YLcBAbuBJMJbgOWZsOceACL/INxw++PgPz385++PND2+8qbCTI6gFBUjwEBk1yFpI1TEKRsEoGAUjAgAAZhlEbY1eAzwAAAAASUVORK5CYII=","orcid":"","institution":"Sun Yat-sen University","correspondingAuthor":true,"prefix":"","firstName":"Junsheng","middleName":"","lastName":"Peng","suffix":""}],"badges":[],"createdAt":"2024-02-01 09:20:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3916812/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3916812/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52035862,"identity":"6c1f318c-314c-4c3c-b3d5-9054831198a6","added_by":"auto","created_at":"2024-03-05 17:04:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22023,"visible":true,"origin":"","legend":"\u003cp\u003eThe hypothesis model of Illness cognition, Dyadic coping and Psychological distress in colorectal cancer patients and their spouses.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3916812/v1/be477c05fec1892f32531c38.png"},{"id":52035865,"identity":"9887e510-762f-4376-9042-3a73aaa50a10","added_by":"auto","created_at":"2024-03-05 17:04:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":252592,"visible":true,"origin":"","legend":"\u003cp\u003eThe hypothesis model of Actor-partner independence mediation model of positive illness cognition, dyadic coping and psychological distress. Note. IC, Illness Cognition; BF, Benefit Finding; DC, Dyadic Coping; PD, Psychological Distress.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3916812/v1/8428b45aad20b1c82a9c1c9a.png"},{"id":52035863,"identity":"10ea965e-9978-4554-9b60-47745a6fe2ce","added_by":"auto","created_at":"2024-03-05 17:04:10","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":40977,"visible":true,"origin":"","legend":"\u003cp\u003eThe hypothesis model of Actor-partner independence mediation model of helplessness, dyadic coping and psychological distress. Note. DC, Dyadic Coping; PD, Psychological Distress.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3916812/v1/c3384ffe2dc852ecddaba791.jpeg"},{"id":68150883,"identity":"d2ca6559-2dc7-4766-8501-e03ea99da2b0","added_by":"auto","created_at":"2024-11-04 07:02:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":973839,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3916812/v1/79f5b7bb-b45c-4971-9cc8-4521f0a7d9b6.pdf"},{"id":52035864,"identity":"2c5257a7-7b9f-4405-8cd3-e3602c52125f","added_by":"auto","created_at":"2024-03-05 17:04:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20932,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixTableS1S2.docx","url":"https://assets-eu.researchsquare.com/files/rs-3916812/v1/ab3741389341bf2e7c8ad01b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dyadic effects of illness cognition and psychological distress among young and middle-aged couples with colorectal cancer: The mediating role of dyadic coping","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAccording to the tumor epidemiology data released by the World Health Organization, the global incidence of colorectal cancer exceeded 1.93\u0026nbsp;million in 2020, making it the third most prevalent malignant tumor. Additionally, approximately 930,000 deaths were attributed to this disease, positioning it as the second highest cause of mortality [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Projections indicate that the burden will rise by 60% by 2030, leading to the emergence of 2.2\u0026nbsp;million newly diagnosed cancer cases and 1.1\u0026nbsp;million cancer-related death [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychological distress, as outlined by the National Comprehensive Cancer Network (NCCN), refers to an emotional encounter triggered by a range of factors, encompassing psychological, social, and spiritual aspects, which are significantly unpleasant [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Acknowledging psychological distress as the sixth vital parameter, the International Psycho-Oncology Society (IPOS) underscores the significance of effectively addressing it in cancer patients as a means to ensure quality cancer care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. According to a study conducted by Dunn et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], 32\u0026ndash;44% of colorectal cancer patients experienced notable psychological distress within five years of their diagnosis. Furthermore, the stress endured by cancer patients can also affect their spouses, resulting in emotional disorders. The psychological burden placed on spouses can further exacerbate the fatigue and depression symptoms experienced by the cancer patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Among couples with rectal cancer, 55% of patients and 78.9% of partners experienced significant psychological distress at the time of diagnosis, which significantly affected their mental and sexual health within one year of diagnosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These results highlight the fact that couples affected by colorectal cancer are part of an emotional system, wherein psychological distress affects both individuals. The onset and medical management of colorectal cancer elevate the vulnerability of both partners to psychological distress. Hence, it is crucial to prioritize the psychological distress of couples dealing with colorectal cancer.\u003c/p\u003e \u003cp\u003eYoung and middle-aged individuals encounter distinctive obstacles in comparison to other age demographics, due to their substantial societal roles and responsibilities in various domains including family, academics, and social spheres. The diagnosis and treatment of cancer hinder their personal development and make it challenging to maintain normal social interactions. Additionally, colorectal cancer in this age group tends to have a more advanced clinical stage and a lower pathological grade, which is characterized by high malignancy and easy metastasis [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Young and middle-aged cancer patients, as well as their partners, display a greater tendency to actively pursue intimate relationships, unlike older patients. However, they frequently encounter challenges in adapting the dynamics of their marital relationship and express apprehensions regarding their interactions with their spouse and their sexual life [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. As a consequence, they experience heightened psychological distress. Taking into account these factors, middle-aged and young patients with colorectal cancer, along with their spouses, face more obstacles compared to patients in other age groups, rendering them more vulnerable to psychological distress [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Psychological emotions are closely linked to quality of life, and the immune and neuroendocrine changes resulting from these emotions play a role in the pathological processes of cancer metastasis, recurrence, and treatment tolerance [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, colorectal cancer patients who experience psychological distress face obstacles in adopting a healthy lifestyle, which in turn diminishes their quality of life and adherence to treatment, ultimately increasing the risk of mortality [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Caregivers of cancer patients facing increased psychological distress also tend to undergo a decline in their overall quality of life [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTransactional Stress Theory and Interpersonal Interdependence Theory all emphasize that the illness constitutes a collective encounter encompassing both patients and their partners. Throughout the course of managing illness, there is a reciprocal relationship among illness cognition, coping mechanisms, and the resulting outcomes, including physical and mental well-being as well as overall quality of life. Extensive research has revealed that various factors such as illness cognition, dyadic coping, and other variables have a substantial influence on the psychological distress encountered by both cancer patients and their partners [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Illness cognition encompasses various cognitive psychological processes, such as assessment, interpretation, and comprehension, undertaken by individuals with a disease to evaluate their health condition and potential treatment options [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Research has indicated that breast cancer patients' positive perception of the illness has a lasting positive impact on their mental well-being and is closely associated with their happiness [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Conversely, negative beliefs about breast cancer among patients can hinder their coping mechanisms and impede their physical and mental recovery, leading to avoidance strategies, delayed medical intervention, and heightened psychological distress [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Spouses of cancer patients who possess negative thoughts and lack effective coping strategies often face heightened psychological distress and diminished psychosocial functioning [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The cognitive understanding of the illness by both the patients and their spouses can influence each other [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In light of the theoretical underpinnings and empirical studies reviewed, we posit that dyadic coping serves as a plausible mediator in the interplay between illness cognition and psychological distress within couples. This hypothesis forms the basis of our conceptual framework, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Participants\u003c/h2\u003e \u003cp\u003eWe used a cross-sectional design for this study, selecting 479 couples with colorectal cancer through convenient sampling. The participants were recruited from two tertiary general hospitals in Guangzhou, China, between May and September 2023.\u003c/p\u003e \u003cp\u003eThe criteria for including couples were as follows: (a) patients who had received a colorectal cancer diagnosis; (b) aged 18\u0026ndash;59 years; (c) informed about their cancer diagnosis, (d) proficient in reading and writing Chinese, and (e) willing to take part in the study. Couples with a history of mental illness, cognitive impairment, or other life-threatening conditions were excluded. This study obtained ethical approval from the Ethics Committee of Nursing School of Sun Yat-sen University and was performed in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eProspective participants were identified via the electronic hospital information system. Upon contact, they were verified for eligibility criteria. After securing informed consent, both patients and their spouses were directed to independently complete the on-site survey, with subsequent quality checks of the completed questionnaires. Each participant required approximately 15\u0026ndash;20 minutes to complete the questionnaires.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Measures\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 General Information\u003c/h2\u003e \u003cp\u003eWe used a tailor-made questionnaire to gather data on demographics and factors related to cancer. The socio-demographic variables encompassed age, educational attainment, employment status, length of marriage, and per capita monthly income. Disease-related characteristics included time of diagnosis, tumor site and presence or absence of stoma.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Illness Cognition Questionnaire\u003c/h2\u003e \u003cp\u003eThe ICQ developed by Evers et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] assesses patients' psycho-behavioral perception of the stress and aversive aspects related to their illness. Han et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] introduced and sinicized ICQ in 2018. The Chinese version of ICQ consists of 18 items in three dimensions, including helplessness, acceptance and perceived benefits, with 6 items in each dimension. We employed a Likert scale, spanning from 1 (completely disagree) to 4 (completely agree), to assess responses. The Chinese version of ICQ exhibited strong internal consistency, with Cronbach's alpha coefficients ranging from 0.86 to 0.88 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Specifically, we utilized the acceptance and perceived benefit subscales to measure positive illness cognition, with a possible score range of 12 to 48. The positive ICQ subscale exhibited robust internal consistency, as reflected by a Cronbach's alpha of 0.81. The text of the questions was adapted to the spouse version of ICQ to make it appropriate for the spouses of patients. For example, \u0026ldquo;my illness\u0026rdquo; in the original questionnaire was changed to \u0026ldquo;my spouses\u0026rsquo; illness\u0026rdquo;. This study used the patient version and spouse version of ICQ to measure the illness cognition of colorectal cancer patients and spouses, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Dyadic Coping Inventory\u003c/h2\u003e \u003cp\u003eThe DCI was utilized to evaluate the collaborative coping strategies employed by partners in response to shared stressors [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The DCI comprises 37 items, encompassing six dimensions: stress communication (8 items), supportive dyadic coping (10 items), delegated dyadic coping (4 items), negative dyadic coping (8 items), common dyadic coping (5 items), and two general dyadic coping items (items 36 and 37) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Responses are rated on a 5-point scale, where 1 indicates \u0026ldquo;very rarely\u0026rdquo;, and 5 corresponds to \u0026ldquo;very often\u0026rdquo;. Out of the 37 items, items 7, 10, 11, 15, 22, 25, 26, and 27 are designated as reverse scoring items. These items are evaluated differently to provide a more accurate assessment. Additionally, items 36 and 37 are specifically used to evaluate self-rated satisfaction using dyadic strategies and are not included in the overall score calculation. The total scores on the DCI ranged from 37 to 175, with higher scores indicating more effective dyadic coping levels. The DCI demonstrated strong internal consistency, as reflected in a Cronbach's α coefficient of 0.92 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.2.4 Kessler psychological distress scale-10\u003c/h2\u003e \u003cp\u003eThe K10 developed by Kessler et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] in 1992, measures the frequency of non-specific mental health symptoms such as anxiety and stress levels experienced by patients in the past 4 weeks, including fatigue, tension, helplessness, restlessness, depression, disinterest, and worthlessness. The scale employs a 5-point rating system, with responses ranging from \"almost never\" to \"all the time\". The total score, ranging from 10 to 50, reflects the level of psychological distress, with a higher score indicating a greater degree of distress. The K10 distress levels were classified into four categories: no psychological distress (10\u0026ndash;15 points), mild psychological distress (16\u0026ndash;21 points), moderate psychological distress (22\u0026ndash;29 points), and severe psychological distress (30\u0026ndash;50 points). Previous research has reported Cronbach's α coefficients for this scale ranging from 0.76 to 0.92 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Sample size\u003c/h2\u003e \u003cp\u003eWe used a simplified method to estimate the sample size, which involved considering 5\u0026ndash;10 times the quantity of study variables [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Given that our study had 17 variables, this approach recommended a sample size range of 85\u0026ndash;170 patients. To account for potential attrition, we factored in a 20% attrition rate, leading to a minimum required sample size of 107 couples.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical analyses\u003c/h2\u003e \u003cp\u003eWe have summarized the sample characteristics using means, standard deviations (SDs), frequencies, and percentages. Pearson\u0026rsquo;s correlation analyses were employed to examine associations among continuous variables (illness cognition, dyadic coping and psychological distress). We employed Amos 28 software to conduct a series of Actor-Partner Independence Models (APIMs) to examine the impact of illness cognition and dyadic coping on psychological distress. This examination encompassed effects on individuals (actor effects) and their respective spouses (partner effects). Initially, we established fully saturated models [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], refining them by eliminating non-significant paths to derive an unsaturated model. We evaluated the fit of the unsaturated model using various indices, including the Comparative Fit Index (CFI\u0026thinsp;\u0026gt;\u0026thinsp;0.90), Normed Fit Index (NFI\u0026thinsp;\u0026gt;\u0026thinsp;0.90), Root Mean Square Error of Approximation (RMSEA\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicating a good fit; RMSEA\u0026thinsp;\u0026lt;\u0026thinsp;0.08 considered acceptable), and the χ\u003csup\u003e2\u003c/sup\u003e/df ratio (χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;\u0026lt;\u0026thinsp;5) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Sample characteristics\u003c/h2\u003e \u003cp\u003eOf all the 479 couples with colorectal cancer who met the inclusion criteria, 45 (9.4%) declined because of having no time or interest, and 31 patients (6.5%) withdrew before completing the survey. In total, 403 dyads effectively completed these questionnaires (84.1%). The median age of colorectal cancer patients and their partners was 49.0 years (IQR\u0026thinsp;=\u0026thinsp;14.00) and 48.0 years (IQR\u0026thinsp;=\u0026thinsp;13.00), respectively. The majority of couples had been married over 20 years (n\u0026thinsp;=\u0026thinsp;257, 63.8%). Over half of the sample were employed, and 53.1% of them had received a colorectal cancer diagnosis within the past 6 months. Further demographic details can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients and spouses (n\u0026thinsp;=\u0026thinsp;403 dyads)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ePartner\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e49.00 (14.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e48.00 (13.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary school or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school/technical secondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity or college education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster degree or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePension/early retirement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of marriage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;19\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;20\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePer capita monthly income (RMB)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e≦\u0026thinsp;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2001\u0026ndash;4000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4001\u0026ndash;8000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;8000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCancer type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColon cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectal cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosis time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithin 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOver 3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStoma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Analysis outlining the characteristics of the study variables\u003c/h2\u003e \u003cp\u003eThe mean scores for positive illness cognition, hopeless, dyadic coping and psychological distress of patients were 32.59 (7.20), 13.80 (4.05), 112.66 (19.64) and 21.04 (7.49), respectively. And the mean scores for positive illness cognition, hopeless, dyadic coping and psychological distress of spouses were 33.73 (7.76), 12.79 (4.23), 113.20 (19.00) and 21.41 (7.78), respectively.\u003c/p\u003e \u003cp\u003eThe scores for positive illness cognition, hopelessness, dyadic coping, and psychological distress exhibited significant correlations between patients and their spouses. Specifically, positive illness cognition, hopelessness, and dyadic coping significantly influenced the psychological distress experienced by patients themselves. Likewise, among the spouses, positive illness cognition, hopelessness, and dyadic coping showed significant associations with their own levels of psychological distress, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Additionally, patients' psychological distress displayed significant correlations with their spouses' positive illness cognition, hopelessness, and dyadic coping, while spouses' psychological distress was significantly associated with patients' positive illness cognition, hopelessness, and dyadic coping, as indicated in Appendix Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/p\u003e \n\u003ctable style=\"border: none;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"border-top:solid windowtext 1.0pt;border-left: solid windowtext 1.0pt;border-bottom:none;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cstrong\u003e\u003cspan style='font-family: \"Times New Roman\",serif;color:black;'\u003eTable 2 Within-Person Bivariate Correlations between Illness cognition, Dyadic coping and Psychological distress\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border-top:solid windowtext 1.0pt;border-left:solid windowtext 1.0pt;border-bottom:none;border-right:none;padding:0in 5.4pt 0in 5.4pt;height:15.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eVariable\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;border-top:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:15.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003ePositive illness cognition\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;border-top:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:15.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eHopeless\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;border-top:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:15.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eDyadic coping\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border-top:solid windowtext 1.0pt;border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt;padding: 0in 5.4pt 0in 5.4pt;height:15.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003ePsychological distress\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border-top:solid windowtext 1.0pt;border-left:solid windowtext 1.0pt;border-bottom:none;border-right:none;padding:0in 5.4pt 0in 5.4pt;height:27.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003ePositive illness cognition\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;border-top:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:27.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style=\"color:black;\"\u003e \u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;border-top:solid windowtext 1.0pt;background:gray;padding:0in 5.4pt 0in 5.4pt;height: 27.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e-.19**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;border-top:solid windowtext 1.0pt;background:gray;padding:0in 5.4pt 0in 5.4pt;height: 27.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e.48**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border-top:solid windowtext 1.0pt;border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt;background: gray;padding:0in 5.4pt 0in 5.4pt;height:27.6pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e-.35**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:21.0pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eHopeless\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"background:#D0CECE;padding:0in 5.4pt 0in 5.4pt;height:21.0pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e-.32**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"padding:0in 5.4pt 0in 5.4pt;height:21.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"background:gray;padding:0in 5.4pt 0in 5.4pt;height:21.0pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e-.26**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;border-right:solid windowtext 1.0pt;background:gray;padding:0in 5.4pt 0in 5.4pt;height: 21.0pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e.57**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:26.4pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eDyadic coping\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"background:#D0CECE;padding:0in 5.4pt 0in 5.4pt;height:26.4pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e.50**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"background:#D0CECE;padding:0in 5.4pt 0in 5.4pt;height:26.4pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e-.34**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"padding:0in 5.4pt 0in 5.4pt;height:26.4pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"border:none;border-right:solid windowtext 1.0pt;background:gray;padding:0in 5.4pt 0in 5.4pt;height: 26.4pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e-.35**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border-top:none;border-left:solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt;border-right:none;padding: 0in 5.4pt 0in 5.4pt;height:22.8pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003ePsychological distress\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"background:#D0CECE;padding:0in 5.4pt 0in 5.4pt;height:22.8pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e-.49**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;border-bottom:solid windowtext 1.0pt;background:#D0CECE;padding:0in 5.4pt 0in 5.4pt;height:22.8pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e.56**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;border-bottom:solid windowtext 1.0pt;background:#D0CECE;padding:0in 5.4pt 0in 5.4pt;height:22.8pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e-.38**\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.8pt;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style=\"color:black;\"\u003e \u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"border:none;padding:0in 5.4pt 0in 5.4pt;height:.45in;\"\u003e\n \u003cp style=\"margin:0in;text-align:justify;font-size:14px;font-family:DengXian;\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eNote. Patients\u0026rsquo; correlates are on lower diagonal and shaded in light grey and spouses correlations on upper diagonal in darker grey. *p\u0026lt;.05, **p\u0026lt;.01, ***p\u0026lt;.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Dyadic effects of positive illness cognition and dyadic coping in psychological distress\u003c/h2\u003e \u003cp\u003eThe standardized estimates for the Actor-Partner Independence Mediation Model (APIMeM) involving positive illness cognition, dyadic coping, and psychological distress can be found in Appendix Table S2 and Model 1 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the course of this analysis, six noteworthy actor effects and two effects pertaining to partners were identified. Moreover, four significant mediating effects were identified within this model. Specifically, the dyadic coping exhibited by both patients and spouses acted as a regulatory factor in mediating the relationship between patients' positive illness cognition and their psychological distress, spouses\u0026rsquo; positive illness cognition and their psychological distress, patients\u0026rsquo; positive illness cognition and their spouses\u0026rsquo; psychological distress, as well as spouses\u0026rsquo; positive illness cognition and patients\u0026rsquo; psychological distress. Specific parameter details are provided in Appendix Table S2. The initial model was presented as a saturated one, limiting our ability to assess model fit with the sample data. To assess the congruence of our proposed hypothesis model with the sample data, we systematically excluded pathways that demonstrated statistical insignificance [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These pathways included positive illness cognition (patient)\u0026rarr;psychological distress (spouse), dyadic coping (patient)\u0026rarr;psychological distress (spouse), positive illness cognition (spouse)\u0026rarr;psychological distress (patient), and dyadic coping (spouse)\u0026rarr;psychological distress (patient). Ultimately, we arrived at an unsaturated model 1 with favorable fit indices (RMSEA\u0026thinsp;=\u0026thinsp;0.069, CFI\u0026thinsp;=\u0026thinsp;0.980, NFI\u0026thinsp;=\u0026thinsp;0.971, CMIN\u0026thinsp;=\u0026thinsp;38.077, DF\u0026thinsp;=\u0026thinsp;13, CMIN/DF\u0026thinsp;=\u0026thinsp;2.929).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Dyadic effects of hopeless and dyadic coping in psychological distress\u003c/h2\u003e \u003cp\u003eStandardized estimates for the APIMeM of hopeless, dyadic coping and psychological distress are found in Appendix Table S2 and model 2 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Six notable actor effects and two effects associated with partners were identified. Moreover, we identified four noteworthy mediation effects: the dyadic coping of both patients and spouses played a regulating role in the connections between patients' hopelessness and psychological distress, spouses' hopelessness and psychological distress, patients' hopelessness and spouses' psychological distress, as well as spouses' hopelessness and patients' psychological distress. Specific parameters can be found in Appendix Table S2. After removing insignificant pathways (hopelessness (patient)\u0026rarr;psychological distress (spouse), hopelessness (spouse)\u0026rarr;psychological distress (patient), dyadic coping (patient)\u0026rarr;psychological distress (spouse), dyadic coping (spouse)\u0026rarr;psychological distress (patient)), the fit indices of Model 2 indicated a strong fit (RMSEA\u0026thinsp;=\u0026thinsp;0.020, CFI\u0026thinsp;=\u0026thinsp;0.999, NFI\u0026thinsp;=\u0026thinsp;0.993, CMIN\u0026thinsp;=\u0026thinsp;4.658, DF\u0026thinsp;=\u0026thinsp;4, CMIN/DF\u0026thinsp;=\u0026thinsp;1.164).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this study, we applied the dyadic approach of the APIMeM to examine the intricate dynamics involving dyadic coping, illness cognition, and psychological distress in colorectal cancer couples who fall into the young and middle-aged demographic categories. We identified substantial actor effects, indicating that positive illness cognition exhibited a strong positive correlation with an individual's own psychological distress in couples. This finding was in accordance with prior research, consistently indicating that positive illness cognition among cancer patients significantly predicts an increase in psychological distress [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A meta-analysis revealed that patients who believed their disease was incurable and uncontrollable faced more physical, emotional, and social challenges compared to those who believed their disease was treatable and controllable [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Previous study has indicated that patients' perception of their illness influences their ability to cope and adapt, including their medical treatment behavior, adherence to treatment, and emotional well-being [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Consequently, this perception indirectly or directly impacts the disease prognosis, patient's quality of life, and social functioning [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Dempster et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] undertook research into the psychological distress experienced by family caregivers of esophageal cancer patients and revealed a noteworthy association between the caregivers' illness cognition and their psychological distress.\u003c/p\u003e \u003cp\u003eSecond, we found that young and middle-aged colorectal cancer who reported better dyadic coping demonstrated less psychological distress and the same results were found in their spouses. Chen et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] conducted an extensive literature review, examining the connection between dyadic coping and outcomes in couples coping with cancer. In the comprehensive review of 28 studies, positive factors like communication, supportive dyadic coping, delegated dyadic coping, and common dyadic coping were linked to stronger marriages, reduced stress, and improved mental health for couples [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Conversely, negative dyadic coping and engagement in protective buffering were associated with reduced relationship satisfaction, lower quality of life, and an increase in depressive symptoms. Regan et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] assessed the psychological distress of prostate cancer couples using the Hospital Anxiety and Depression Scale. The results indicated that for patients, depression was related to their own supportive dyadic coping, spouses' negative coping, and common coping. For spouses, spouses\u0026rsquo; anxiety was correlated with their own and partner's negative dyadic coping, but depression was not correlated with dyadic coping. Additionally, Lim et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] highlighted the interaction between coping and psychological distress of couples with cancer. This underscores the bidirectional influence of anxiety and depression between patients and their spouses, emphasizing the significance of comprehensive coping strategies tailored to benefit the mental health of both individuals.\u003c/p\u003e \u003cp\u003eThird, our findings indicated that the dyadic coping of patients and their spouses was influenced by their individual and their partners' positive illness cognition. A study conducted by Checton et al [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. revealed that patients' illness cognition could have a negative impact on their dyadic coping. A systematic review found increased engagement in avoidance coping was linked to an increased perception of the severity of cancer and a reduced understanding of illness coherence [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Conversely, individuals possessing a heightened sense of personal control are more inclined to actively employ coping strategies [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Therefore, recognizing the disease in a positive light is crucial for the coping mechanisms of young and middle-aged couples with colorectal cancer.\u003c/p\u003e \u003cp\u003eFurthermore, our findings suggest that couples using dyadic coping strategies played a vital role in mediating the link between positive illness cognition and psychological distress. Additionally, these coping strategies were shown to mediate the connection between patients' positive illness cognition and psychological distress experienced by their spouses. It is evident that individuals diagnosed with cancer and their spousal caregivers share comparable emotional reactions when confronted with the challenges of a cancer diagnosis and treatment, including distress, anxiety, depression, fear, uncertainty, and denial [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. A study conducted on lung cancer patients and found that the way patients perceive their illness can directly impact their psychosocial adaptation during chemotherapy [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The study also found that coping strategies play a crucial role in this relationship. Patients who hold negative perceptions of their condition often adopt different coping mechanisms to improve their mental well-being and adjust to the challenges associated with the disease. Conversely, embracing positive coping styles can result in a more favorable perception of cancer and enhance overall psychosocial adaptation. On the other hand, relying on negative coping strategies can diminish positive perceptions of cancer and hinder recovery outcomes.\u003c/p\u003e \u003cp\u003eOur research findings shed light on the correlation between helplessness, dyadic coping, and psychological distress among young and middle-aged couples dealing with colorectal cancer. A study conducted by Lyons et al. [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. revealed that the evaluation and coping strategies of couples facing lung cancer have a substantial impact on the psychological well-being of both individuals, even when accounting for situational factors. Model 2 examines the negative effects of helplessness on self-reported psychological distress in couples. It hinders the development of dyadic coping and weakens the spouse's psychological well-being. Valentine et al. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] studied the relationship between illness cognition, coping, and psychosocial adaptation in lung cancer patients. And the findings indicate that illness cognition directly impacts the psychosocial adaptive ability of patients undergoing chemotherapy, and this impact can be further enhanced through the adoption of coping strategies. Patients with more adverse perceptions typically employ various coping strategies to better adapt to the challenges brought on by the disease. Therefore, addressing helplessness in young and middle-aged couples facing colorectal cancer is crucial. Implementing positive psychology techniques is recommended to alleviate psychological distress in both patients and their partners.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Study limitations\u003c/h2\u003e \u003cp\u003eOur study has certain limitations that warrant acknowledgment. Firstly, despite the relatively substantial sample size, our study involved young and middle-aged colorectal cancer survivors, along with their spouses, recruited from two medical centers, which may not accurately represent a wider population. Secondly, due to the reliance on self-reported data, it is essential to interpret the findings with caution. Thirdly, this cross-sectional design hinders the capability to investigate the dynamic evolution of psychological distress and establish causal relationships. Longitudinal studies are needed to better understand the psychological distress in both partners throughout the journey from the initial cancer diagnosis to recovery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Implications for Practice\u003c/h2\u003e \u003cp\u003eOur findings indicate that interventions aimed at reducing psychological distress in young and middle-aged couples with colorectal cancer should take into account both individuals within the couple. It is important to promote positive illness cognition by encouraging acceptance and perceived benefits. Additionally, to enhance dyadic coping, it is recommended to foster positive communication while simultaneously diminishing blame and avoidance. Fostering positive illness cognition was not only beneficial to one\u0026rsquo;s own dyadic coping but also beneficial to that of his/her spouse. Furthermore, our study found that dyadic coping plays a mediating role between positive illness cognition/helplessness and psychological distress in colorectal cancer couples. Therefore, these approaches can be utilized to develop interventions that enhance dyadic coping, ultimately leading to reduced couples\u0026rsquo; psychological distress.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eOur findings underscored that in couples, positive illness cognition and dyadic coping were positive predictors of psychological distress, while helplessness served as a negative predictor. These mediation results suggest the central approach for mitigating psychological distress involves enhancing positive illness cognition, reducing helplessness, and strengthening dyadic coping.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e The study has been approved by the Ethics Committee of Nursing School of Sun Yat-sen University (No. L2023SYSU-HL-004) and performed in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eI declare that the authors have no competing interests as defined by Springer, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFUNDING STATEMENT\u003c/h2\u003e \u003cp\u003eNo external funding was used for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll listed authors (A. B. C. D. E.) meet the authorship criteria and that all authors are in agreement with the content of the manuscript. All the authors substantially contributed to the (1) design of the study, (2) data extraction, data analysis and interpretation, (3) drafting of the article and (4) approval the final version for publication.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL et al (2021) Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 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Eur J Oncol Nurs 54:102035. https://doi.org/10.1016/j.ejon.2021.102035\u003c/li\u003e\n\u003cli\u003eLim JW, Shon EJ, Paek M, Daly B (2014) The dyadic effects of coping and resilience on psychological distress for cancer survivor couples. Support Care Cancer 22:3209-3217. https://doi.org/10.1007/s00520-014-2334-9\u003c/li\u003e\n\u003cli\u003eChecton MG, Magsamen-Conrad K, Venetis MK, Greene K (2015) A dyadic approach: applying a developmental-conceptual model to couples coping with chronic illness. Health Educ Behav 42:257-267. https://doi.org/10.1177/1090198114557121\u003c/li\u003e\n\u003cli\u003eRichardson EM, Sch\u0026uuml;z N, Sanderson K, Scott JL, Sch\u0026uuml;z B (2017) Illness representations, coping, and illness outcomes in people with cancer: a systematic review and meta-analysis. Psychooncology 26:724-737. https://doi.org/10.1002/pon.4213\u003c/li\u003e\n\u003cli\u003eGoldzweig G, Schapira L, Baider L, Jacobs JM, Andritsch E, Rottenberg Y (2019) Who will care for the caregiver? Distress and depression among spousal caregivers of older patients undergoing treatment for cancer. Support Care Cancer 27:4221-4227. https://doi.org/10.1007/s00520-019-04711-6\u003c/li\u003e\n\u003cli\u003eValentine TR, Presley CJ, Carbone DP, Shields PG, Andersen BL (2022) Illness perception profiles and psychological and physical symptoms in newly diagnosed advanced non-small cell lung cancer. Health Psychol 41:379-388. https://doi.org/10.1037/hea0001192\u003c/li\u003e\n\u003cli\u003eLyons KS, Miller LM, McCarthy MJ (2016) The Roles of Dyadic Appraisal and Coping in Couples With Lung Cancer. J Fam Nurs 22:493-514. https://doi.org/10.1177/1074840716675976\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"illness cognition, dyadic coping, psychological distress, colorectal cancer, couples","lastPublishedDoi":"10.21203/rs.3.rs-3916812/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3916812/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eYoung and middle-aged colorectal cancer patients, along with their spouses, face heightened vulnerability to psychological distress. The psychological distress of both patients and their partners may be influenced by illness cognition and dyadic coping. To explore the dyadic interplay of illness cognition, dyadic coping, and psychological distress, we aimed to validate dyadic coping as a mediator between illness cognition and psychological distress.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted our study with 403 pairs of young and middle-aged patients with colorectal cancer and their partners, recruited from two tertiary hospital between May and September 2023. Participants completed questionnaires measuring illness cognition, dyadic coping and psychological distress.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur results revealed that both patients and spouses exhibited actor effects and partner effects regarding positive illness cognition/helplessness on dyadic coping. However, dyadic coping only had actor effects on psychological distress. Furthermore, we verified that dyadic coping mediates the link between positive illness cognition/helplessness and psychological distress.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThese results offer fresh insights into the relationship of illness cognition, dyadic coping, and psychological distress at both individual and dyadic levels. They underscore the importance of promoting positive illness cognition and reducing helplessness in the context of cancer care. Healthcare providers play a crucial role in easing couples' psychological distress through the promotion of positive illness cognition and the reduction of feelings of helplessness.\u003c/p\u003e","manuscriptTitle":"Dyadic effects of illness cognition and psychological distress among young and middle-aged couples with colorectal cancer: The mediating role of dyadic coping","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-05 17:04:06","doi":"10.21203/rs.3.rs-3916812/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ee676bfa-be30-4855-ba23-313113ba50e8","owner":[],"postedDate":"March 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-04T06:54:09+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-05 17:04:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3916812","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3916812","identity":"rs-3916812","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}