Factors associated with the fear of disease progression in older spousal caregivers of patients with cancer: a cross-sectional study

Factors associated with the fear of disease progression in older spousal caregivers of patients with cancer: a cross-sectional study | 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 Factors associated with the fear of disease progression in older spousal caregivers of patients with cancer: a cross-sectional study Ruirui Qiu, Yuli Li, Yaoyi Pan, Lan Ye, Chunyu Ren, Qingyan Zhou, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6533203/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Nov, 2025 Read the published version in BMC Nursing → Version 1 posted 12 You are reading this latest preprint version Abstract Aim To describe the fear of disease progression levelin the older spousal caregivers of patients with cancer in China and explore factors associated with the fear of disease progression and the complex relationships among these factors. Background The older spousal caregivers of patients with cancer might have a high level of fear of disease progression, which is greater than that perceived by patients. However, there is a lack of attention given to the influencing factors of fear of disease progression among older spousal caregivers of patients with cancer. Design This study followed a cross-sectional design. Methods: A total of 210 older spousal caregivers of patients with cancer were eligible to complete the general sociodemographic and disease questionnaire, the Chinese version of the Fear of Disease Progression Questionnaire-Short-Form for Partners, Form C of the Multidimensional Health Locus of Control Scale, the Family Avoidance of Communication about Cancer Scale, and the Brief Health Literacy Assessment. The data were analyzed via univariate analysis, Pearson correlation analysis, multiple linear regression analysis, structural equation modeling, and a bootstrap mediation effect test. Results The older spousal caregivers of patients with cancer had high total scores for fear of disease progression (35.21±9.79). Powerful-other health locus of control and health literacy were significantly negatively correlated with fear of disease progression, respectively(P<0.01), whereas family avoidance of communication about cancer was significantly positively correlated with fear of disease progression (P<0.01). Moreover, family avoidance of communication about cancer and health literacy had a chain mediating effect between powerful-other health locus of control and fear of disease progression. Conclusions Fear of disease progression among older spousal caregivers of patients with cancer can be reduced by the use of nursing strategies to control available sources, especially the powerful-other health locus of control, encouraging family communication about cancer, and improving health literacy. older spouse caregiver cancer fear of disease progression health locus of control family communication health literacy Figures Figure 1 Figure 2 1. Introduction According to global cancer statistics, nearly 20 million new cancer cases were diagnosed worldwide in 2022, and this number is expected to reach 35 million by 2050 [ 1 ]. Moreover, 78% of patients with cancer are aged 60 years and older [ 2 ]; thus, older patients with cancer and their spouses constitute a large group. During the diagnosis and treatment of cancer, patients' spouses are their closest and primary social supporters, so spouses must also experience potential adverse effects and psychological distress. The negative emotions of patients with cancer are interrelated with those of their spouses and affect each other. In recent years, with improvements in diagnostic and treatment technologies, the fear of cancer recurrence and progression has become a common problem affecting patients and their families [ 3 ]. Fear of disease progression (FoP) refers to an individual's fear of all diseases related to their current condition. This is specifically defined as a reactive and conscious fear of the various biological, social, and psychological consequences arising from disease progression or recurrence [ 4 ]. Previous studies have shown that the fear of disease progression is high in both patients with cancer and their spouses [ 5 ], with some studies showing that spouses score higher in terms of FoP than do patients themselves [ 6 ]. At present, the psychological interaction between patients with cancer and their spouses has become a research focus [ 7 ]; however, there is a lack of interest in psychological and influencing factors among spouses of patients with cancer. This study was conducted among a large population of older patients with cancer. The family model of predictors of fear of cancer recurrence highlights that fear in patients with cancer and their family members is affected by individual, family, and social factors [ 8 ]. Therefore, in this study, we explored the factors influencing FoP from these perspectives. Understanding the factors influencing FoP in the spouses of patients with cancer will help to provide a theoretical basis for formulating psychological intervention measures for this population. In the face of enormous stress after a cancer diagnosis, family members often experience negative effects, depending on their own beliefs. As an attributional psychological factor, health locus of control (HLC) refers to an individual's intuition and causal beliefs about the determinants of their own health, which emphasize the degree to which an individual believes that health is controlled by internal or external factors. This can directly affect and predict whether an individual will adopt certain health behaviors [ 9 ]. Studies have shown that the management of individual locus of control helps develop individual potential, improve and maintain their individual positive mental state and health behaviors and is closely related to the health management of patients with cancer [ 10 ]. Therefore, HLC may be associated with psychological barriers related to FoP. With ongoing investigations into FoP, the scope of research has gradually expanded from a single patient to a whole group of patients and their spouses. However, in the context of cancer, patients and family members usually hide their feelings to protect each other, resulting in a lack of direct communication or limiting communication between the two parties [ 11 ]. This communication method, in which both parties are unwilling to openly exchange cancer-related information and feelings, is referred to as the family's avoidance of cancer communication [ 12 ]. Research on breast cancer indicates that communication between partners has a significant effect on spouses’ FoP [ 13 ]. Previous studies among patients with breast cancer and their spouses have shown that family avoidance of cancer communication has a mediating role between mindfulness and fear of cancer recurrence [ 14 ]. Moreover, HLC is recognized as a factor affecting the development and promotion of health behaviors [ 15 ], whereas family avoidance of cancer communication is unhealthy behavior. However, little is known about the relationship between HLC and family avoidance of cancer communication. However, a previous study revealed that locus of control can impact patient–provider communication [ 16 ]. Therefore, it is speculated that family avoidance of cancer communication may also have a mediating effect on the relationship between HLC and FoP. With the rapid development of network information technology and the use of smartphones, the internet can provide older people with a variety of online health resources and medically related information to help them manage their health and psychological problems [ 17 ]. Although the internet can provide resources for individuals seeking knowledge about health conditions and treatments, this does not mean that people can always use these resources correctly to help solve existing health problems [ 18 ]. Health literacy refers to the ability of individuals to obtain, process, and understand basic health information and services and to use such information and services to make appropriate health decisions [ 19 ]. Studies among patients with newly diagnosed breast cancer have shown that limited health literacy is associated with greater FoP [ 20 ]. However, the situations and psychological statuses of patients and their spouses are different. Therefore, health literacy may also be associated with the fear of disease progression among older spousal caregivers of patients with cancer. When a patient's spouse is aware that the doctor or family and friends will have an impact on the patient’s recovery from cancer, they will actively and effectively communicate with the doctor and family to obtain health information and make correct health decisions; this can be regarded as the patient receiving external support. However, when patients have low health literacy, communication with family, doctors, or friends about health problems is ineffective. Thus, health locus of control may affect health literacy and family communication. Previous studies have shown that health literacy has a mediating effect on the relationship between perceived control and self-management [ 21 ]. It is speculated that health literacy may play a mediating role in the relationship between health locus of control and fear of disease progression. Health literacy is defined by the Canadian Public Health Association as the ability of individuals to obtain, understand, evaluate, and exchange information to promote, maintain, and improve health at different times during a person's life [ 22 ]. Therefore, communication among family members is conducive to the acquisition of information about the disease, the evaluation of treatment effects, and making correct health-related decisions. Thus, family avoidance of cancer communication may also have an effect on health literacy. In summary, we propose the following hypothesis: family avoidance of communication about cancer and health literacy have a chain mediating effect on the relationship between the health locus of control and the fear of disease progression. A hypothesis model diagram is shown in Fig. 1 . 2. Methods 2.1 Study design and participants Using a convenience sampling method, we selected older spousal caregivers of patients with cancer who were hospitalized in the Oncology Department of two Class III Grade A hospitals in Shandong Province from December 2023 to April 2024. According to the sample size estimation method of Kendall [ 23 ], the sample size of descriptive research was 5–10 times the number of variables. The four research variable scales used in this study cover a total of 8 dimensions. Considering the failure rate of 20% of the questionnaires, the sample size was estimated to be 50 to 100 cases. Thus, a total of 210 samples were collected to meet the sample size requirements. The inclusion criteria as follows: ① patients with cancer cared for by their spouses had a tumor, node, or metastasis (TNM) ≤stage III; ② the spouse had an age ≥ 60 years; ③ the spouse was the primary caregiver for the patient, had at least a primary school education, and was involved in the patient's medical decision-making; ④ the spouse had no history of mental illness and spoke clearly; and ⑤ the spouse voluntarily participated in the study. ⑥ Using the Mini-Mental State Examination to screen the spouse for dementia. The exclusion criteria as follows: ① patients with cancer who had recurrence or distant metastasis; ② spouses whohad severe heart, lung, kidney or other major organ dysfunction; ③ spouses with mental or cognitive impairment or dementia; and ④ spouses with serious auditory, visual, or language barriers. 2.2 Measurement We selected scales suitable for use in older populations, which have been validated and have excellent reliability and sensitivity. 2.2.1 General sociodemographic and disease survey This survey included information about the older spousal caregivers of patients, such as sex, age, residence, educational level, occupation, family monthly income, number of children, and number of chronic diseases. Patient information included self-care ability, family history of cancer, disease duration and TNM stage. 2.2.2 Chinese Fear of Disease Progression Questionnaire-Short-Form for Partners (FOP-Q-SF/P) The Chinese version of the FOP-Q-SF/P [ 24 ] was used to assess the level of FoP in a patient's spouse. The FOP-Q-SF/P includes two dimensions, physical health and social family function and has a total of 12 items. The scale is scored on a 5-point Likert scale. The minimum score is 12 and the maximum score is 60, with higher scores indicating greater fear of disease progression. A score of ≥ 34 is considered a borderline score related to mental dysfunction owing to FoP [ 25 ]. The scale has good reliability and validity, and the Cronbach's α coefficient in the present study was 0.89. 2.2.3 Form C of the Multidimensional Health Locus of Control (MHLC-C) The Chinese version of the MHLC-C was used to measure sources of control in patients aged 18 years and older in medical settings [ 9 , 26 ]. The MHLC-C scale contains a total of 18 items, with three main subscales—internal health locus of control (HLC), chance HLC and powerful-others HLC (PHLC). Each item uses a 6-point Likert scale. The score of each subscale is the sum of the scores of the items under that subscale. The highest score among the three subscales determines the patients' type of health locus of control. The Cronbach's α coefficient in this study was 0.86. 2.2.4 Family Avoidance of Communication about Cancer Scale (FACC) The Chinese version of the FACC was used to measure the perceived degree of openness or avoidance of family cancer-related communication among patients with breast cancer and their family caregivers [ 27 ]. The scale has five items and uses a 5-point Likert scale. For each item, the spouse selects the number that best matches their disease communication situation during the past month. The original total scale score is the average of the five items. The original score and total score of the scale are subsequently converted into a standard score ranging from 0 to 100 points. The standard score is calculated as (original score − 1)/4×100, with higher scores indicating more family avoidance of cancer-related communication. The Cronbach's α coefficient of the scale in this study is 0.90. 2.2.5 Brief Health Literacy Assessment Scale The Chinese mainland version of the Brief Health Literacy Assessment Scale was used to evaluate self-perceived health literacy in older patients [ 28 ]. The scale includes two dimensions and 10 items that use a 5-point Likert scale. The total score ranges from 10 to 50 points, with higher scores indicating better health literacy. According to the criteria developed by National Health Literacy Monitoring [ 29 ], 80% of the scale score (40 points) was taken as the threshold for qualified health literacy in this study, with a score of ≥40 points indicating qualified health literacy. In this study, the Cronbach's α coefficient of the scale was 0.96. 2.3 Procedure A face-to-face paper questionnaire survey was conducted in this study. The purpose and importance of the study were explained to participants before they completed the questionnaire, after the consent of patients’ spouses was obtained. If participants could not complete the form independently, the investigators read each item to them and completed the questionnaire on the basis of the participants’ responses. Questionnaires were distributed and collected on the spot, and missing items were checked to ensure data integrity. Therefore, all the collected data had no missing data. Data were entered by two individuals. A total of 230 questionnaires were distributed and 210 valid questionnaires were collected, resulting in an effective recovery rate of 91.30%. 2.4 Ethical considerations In this study, all methods were performed by the relevant guidelines and regulations. The study was approved by the Ethics Committee of the Second Hospital of Shandong University (approval number: KYLL2024468). All procedures were by the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration. The data was collected after informed consent and written consent were obtained from each participant. 2.5 Statistical analysis IBM SPSS 24.0 was used for the data analysis. Categorical data are presented as frequencies and percentages, and continuous data are presented as the means ± standard deviations. Univariate analysis, Pearson correlation analysis, and multiple linear regression analysis were used to determine the variables included in the structural equation model. AMOS 26.0 was used to construct the structural equation model and the bootstrap method was used to test the mediating effect. A P value < 0.05 was considered to indicate statistical significance. 3 Results 3.1 Sociodemographic characteristics In this study, most participants were aged 60–69 years. Patients with cancer were mainly from rural areas, had a junior high school education, worked in farming, and had medical insurance for residents. The average disease duration of the patients was 12.68 ± 19.57 months. For details, see Table 1 ; the upper part shows the information of the spouses of the cancer patients, and the lower part shows the information of the cancer patients. Table 1 Sociodemographic characteristics and univariate analysis results (N = 210) Variables Group n Percentage(%) FoP score F P LSD-t The older spousal caregivers of patients Sex Male 114 54.3 34.58 ± 9.69 1.04 0.31 Female 96 45.7 35.96 ± 9.90 Age(years) 60–69 192 91.4 35.18 ± 9.75 0.08 0.93 70–79 17 8.1 35.29 ± 10.82 ≥ 80 1 0.5 39.00 ± 0.00 Residence ①Rural 84 40.0 36.17 ± 11.37 3.05 0.05 ②>③ ②Town 54 25.7 36.74 ± 7.65 ③City 72 34.3 32.94 ± 8.90 Educational level Primary school or below 21 10 32.38 ± 12.88 1.23 0.30 Junior high school 71 33.8 35.61 ± 10.26 Senior high school or technical secondary school 64 30.5 36.89 ± 9.77 Junior college or higher vocational school 19 9.0 33.68 ± 7.57 Bachelor degree or above 35 16.7 33.86 ± 7.34 Occupation Vocational institution or state-owned enterprise 53 25.2 34.02 ± 9.22 0.68 0.61 Private sector 31 14.8 34.35 ± 9.14 Self-employed 41 19.5 35.07 ± 9.09 Farmers 65 31.0 36.78 ± 10.76 Unemployed 20 9.5 34.85 ± 10.56 Family monthly income(RMB) ≤ 1000 48 22.9 35.21 ± 11.79 1.16 0.33 1000–5000 95 45.2 36.36 ± 9.79 5000–10000 50 23.8 33.20 ± 7.95 > 10000 17 8.1 34.71 ± 8.16 Number of children ≤ 1 87 41.4 34.09 ± 8.61 2.19 0.11 2–3 113 53.8 36.41 ± 10.61 > 3 10 4.8 31.40 ± 8.34 Number of diseases 0 164 78.1 35.56 ± 10.15 0.81 0.45 1–2 42 20 33.60 ± 8.57 ≥ 3 4 1.9 37.75 ± 4.99 The patients Self-care ability ①Cannot care for self 7 3.3 35.91 ± 10.47 3.10 0.05 ②>③ ②Partial self-care 41 19.5 38.51 ± 9.70 ③Full self-care 162 77.1 34.30 ± 9.64 Family history of cancer No 177 84.3 34.99 ± 10.00 0.57 0.45 Yes 33 15.7 36.39 ± 8.64 TNM staging ①I 60 28.6 30.78 ± 7.93 6.25 0.00 ①<② ②II 24.3 24.3 37.29 ± 8.79 ①<③ ③III 31.4 31.4 36.53 ± 10.28 ①<④ ④Unclear 15.7 15.7 37.39 ± 11.07 3.2 Univariate analysis of the fear of disease progression The results of the univariate analysis (Table 1 ) revealed that the fear of disease progression varied in terms of residence, self-care ability, and TNM stage. Moreover, post hoc multiple comparisons revealed that FoP among town dwellers was greater than that among city dwellers and that the level of partial self-care was greater than that of complete self-care. TNM stage I was lower than the other phases were. 3.3 Correlation analysis among the study variables The score for FoP was 35.21 ± 9.79. Pearson correlation analysis (Table 2 , end of text) showed that health locus of control, powerful-others HLC and health literacy was significantly negatively correlated with fear of disease progressio Table 2 Correlations among health locus of control, family avoidance of cancer communication, health literacy and FoP ( r , N = 210) Variables M ± SD 1 2 3 4 5 6 7 8 9 10 11 1.Fear of disease progression 35.21 ± 9.79 1 2.Physical health 22.34 ± 6.20 0.94 ** 1 3.Social family function 9.71 ± 3.74 0.81 ** 0.56 ** 1 4.Health locus of control 64.10 ± 13.36 −0.17 * -0.16 * -0.09 1 5.Internal locus of control 21.72 ± 4.60 0.11 0.10 0.13 0.72 ** 1 6.Powerful-others HLC 22.76 ± 8.32 -0.34 ** -0.30 ** -0.27 ** 0.76 ** 0.23 ** 1 7.Chance HLC 19.62 ± 5.36 0.01 -0.01 0.07 0.69 ** 0.57 ** 0.15 * 1 8.Family avoidance of communication about cancer 45.60 ± 29.51 0.32 ** 0.32 ** 0.22 ** -0.24 ** -0.04 -0.34 ** -0.03 1 9.Health literacy 36.38 ± 8.39 -0.31 ** -0.28 ** -0.25 ** 0.41 ** 0.24 ** 0.41 ** 0.18 * -0.28 ** 1 10.Health information literacy 21.36 ± 5.16 -0.32 ** -0.29 ** -0.26 ** 0.41 ** 0.24 ** 0.42 ** 0.17 * -0.28 ** 0.97 ** 1 11.Communication literacy 15.02 ± 3.59 -0.27 ** -0.24 ** -0.22 ** 0.36 ** 0.22 ** 0.36 ** 0.16 * -0.26 ** 0.94 ** 0.84 ** 1 Note: * P < 0.05; ** P < 0.01. M = mean, SD = standard deviation. The FoP score was 35.21 ± 9.79. Pearson correlation analysis (Table 2 , end of the text) revealed that health locus of control, powerful-other HLC and health literacy were significantly negatively correlated with fear of disease progression (r=-0.17, P0.05; r=-0.34, P<0.01; and r=-0.31, P<0.01, respectively), whereas family avoidance of communication about cancer was significantly positively related to fear of disease progression (r = 0.32, P<0.01). 3.4 Multiple linear regression analysis of fear of disease progression Multiple linear regression analysis (Table 3 ) was used to analyze factors related to FoP with the significant variables as dependent variables according to univariate analysis and correlation analysis. Model 1 included residence, self-care ability, and TNM stage, and the adjusted R 2 was 0.09(P<0.001). Model 2 was further adjusted for powerful-other HLC and family avoidance of cancer communication and health literacy, and the adjusted R 2 was 0.22 (P<0.05). Table 3 Results of multivariate linear analysis (N = 210) Variables Model 1 Model 2 B β t B β t Intercept 32.21 10.01 43.25 9.42 Residence (town) 1.39 0.06 0.83 0.39 0.02 0.25 Residence (city) −2.49 −0.12 −1.60 −1.89 −0.09 −1.28 Partial care 1.58 0.06 0.49 0.43 0.02 0.15 Full care −1.18 −0.05 −0.40 −2.08 −0.09 −0.76 TNM stage ΙΙ 6.00 0.26 3.31 ** 5.03 0.22 2.96 *** TNM stage ΙΙΙ 5.57 0.27 3.33 ** 4.71 0.22 3.01 *** TNM stage unclear 5.49 0.21 2.59 * 3.28 0.12 1.63 Health literacy −0.22 −0.19 −2.74 *** Family avoidance of communication about cancer 0.06 0.18 2.57 ** Powerful-others HLC −0.18 −0.15 −2.10 ** R 2 0.12 *** 0.26 *** Adjusted R 2 0.09 *** 0.22 *** F 3.97 *** 6.90 *** Note: * P < 0.05; ** P < 0.01; *** P < 0.001. 3.5 Chain mediating effect of family avoidance of cancer communication and health literacy on the relationship between health locus of control and fear of disease progression The Harman single-factor test method [ 30 ] was used. The test results revealed that there were 8 factors with eigenvalues greater than 1, and the first factor explained 24.88% of the variance, which was less than the critical standard of 40%, indicating that there was no obvious common method deviation in the data of this study. In this study, TNM stage was used as a control variable according to the multiple linear regression analysis results; powerful-other HLC subscale of health locus of control was used as the independent variable; family avoidance of communication about cancer and health literacy were used as the mediating variables; and FoP was used as the dependent variable. The final structural equation model (Fig. 2 ) with the maximum likelihood method was acceptable, with a good model fit index: χ 2 /df = 0.264 0.900, RMSEA = 0.000 0.900, AGFI = 0.991 > 0.900 [ 31 , 32 ]. The results of the mediation effect test are shown in Table 4 . Table 4 Mediation effect test results Path of influence Effect size Proportion of relative effects (%) Boot standard error 95%CI Total effect −0.36 100 0.07 −0.51 ~ − 0.21 Direct effect −0.20 55.56 0.08 −0.36 ~ − 0.04 Indirect effect −0.16 44.44 0.04 −0.26 ~ − 0.09 Powerful-others HLC→Family avoidance of communication about cancer→Fear of disease progression −0.07 19.44 0.03 −0.15 ~ − 0.02 Powerful-others HLC→Health literacy →Fear of disease progression −0.08 22.22 0.03 −0.14 ~ − 0.03 Powerful-others HLC→Family avoidance of communication about cancer→Health literacy→Fear of disease progression −0.01 2.78 0.01 −0.03 ~ − 0.01 4 Discussion This study aimed to trace the level of FoP among older spousal caregivers of patients with cancer and the mediating effects of family avoidance of cancer communication and health literacy on the relationship between HLC and FoP. Studies have begun to focus on the FoP of the spouses of cancer patients [ 33 , 34 ] and one has shown a significant correlation between age and caregiver FoP [ 35 ]. However, older spouse caregivers of cancer patients continue to receive less attention. The present study explored potential mechanisms affecting FoP from multiple perspectives among older spousal caregivers of patients with cancer. The results suggested that family avoidance of communication about cancer could positively affect the FoP of older spousal caregivers, whereas HLC and health literacy had negative impacts on the FoP of older spousal caregivers. Therefore, this study provides ideas for reducing the FoP of older spousal caregivers, emphasizing the role of HLC, family avoidance of communication, health literacy and other associated factors. As an important factor affecting life expectancy, the recurrence and metastasis of cancer have yet to be conquered [ 1 ], so disease progression remains a concern for cancer patients and their caregivers. The results of this study revealed that the level of FoP among older spousal caregivers of patients with cancer exceeded normal and that these patients had dysfunction in FoP (35.21 ± 9.79 ≥ 34), which is similar to the findings of previous studies [ 5 , 36 ]. A high level of FoP among older spousal caregivers impacts their physical and mental health, reduces their ability to provide care and affects their and patients’ quality of life [ 37 , 38 ]. The results revealed that the current status of FoP among older spousal caregivers of patients with cancer was not encouraging and required urgent attention and effective help from health care professionals. Moreover, the present study identified several sociodemographic characteristics associated with older spousal caregivers’ FoP, including residence, self-care ability, and TNM stage. While this study failed to find a significant relationship between age and FoP, one conjecture about this phenomenon is that all those included in this study were over 60 years of age, which is not a large span. In this study, older spousal caregivers living in towns had greater FoP than did those living in cities. This might be because town residents are under more financial pressure, such as insurance, and often have to leave their place of living to take care of patients in hospitals, where tertiary hospitals are often in the city. This study revealed a statistically significant impact of TNM stage, with older spousal caregivers having the lowest levels of FoP for patients in TNM stage I patients. This may be related to the medical characteristics of TNM stage I patients, with a low recurrence rate of cancer [ 39 ], which buffers FoP for older spousal caregivers. The HLC measurements indicated that older spousal caregivers tend to be PHLCs, who believe that health relies on the guidance and care of authorities, echoing previous research showing that older adults are more inclined to trust powerful others[ 40 ]. The reason may be that in the face of the significant event of their partner's cancer, older spousal caregivers generally believe that they are unable to change the patient's state of illness on their own and therefore place the patient's restoration of health in the hands of health care professionals and become physically and psychologically more reliant on their help and support. Additionally, the correlation analysis further confirmed that HLC and PHLC were negatively correlated with FoP. Specifically, the stronger older spousal caregivers’ perceptions of the source of control over their health event are, the lower their FoP may be. Older spousal caregivers were more trusting of health care professionals, making it more effective to change their adverse perceptions, reduce their negative emotions and decrease FoP through health care professional interventions. In this study, PHLC was found to have a significantly negative effect on family avoidance of communication about cancer, whereas family avoidance of communication about cancer was found to have a positive influence on FoP in older spouse caregivers. Furthermore the mediating role of family avoidance of communication about cancer between PHLC and FoP was also illustrated. These findings suggeste that as older spouse caregivers tend to PHCL more, they might be more willing to discuss things related to cancer, which could lead to a reduction in their fear of cancer progression. Effective communication has been identified as a key factor in managing family tension and regulating coping mechanisms [ 41 ], which is particularly relevant for older spousal caregivers. Therefore, effective interventions are important to promote older spouse caregivers’ PHLC, allowing them to communicate freely with patients to overcome communication barriers and ultimately facilitating their freedom from the fear of disease progression. In the present study, the health literacy of older spouse caregivers was inadequate, which was consistent with the results of a prior report [ 42 ]. Lorini et al. also confirmed higher rates of inadequate health literacy in older spousal caregivers with dementia. In addition, this study revealed that health literacy was positively affected by PHLC but could negatively predict the FoP of older spouse caregivers. Moreover, this study substantiated the mediating role of health literacy in the relationship between PHLC and FoP in older spouse caregivers. This might be explained by the fact that older spouse caregivers in PHLC are more trusting of health care professionals, which prompts them to follow medical advice and have better communication literacy, which in turn helps to increase their acceptance of information about cancer, reduces their psychological stress, and improves their physical health. The present study further confirmed that the relationship between PHLC and FoP was serially mediated by family avoidance of communication about cancer and health literacy. Those with high PHLC tended to attribute their health status to powerful others, have good compliance, tend not to avoid or minimize the behavior of discussing cancer-related information and feelings, access more health information and apply it to themselves and patients, thus reducing the fear of cancer progression. With improvements in cancer treatment technology and increased survival [ 43 ], patients need to undergo a long course of treatment and recovery, and their caregivers also have long periods of care. According to these findings, during this long period of fighting cancer, it is essential that older spousal caregivers are empowered with PHLC, believe in health care professionals and are more willing to communicate with patients about cancer to understand the feelings and thoughts of both parties. Health care professionals also need to be clear about the needs of older spousal caregivers and provide guidance and health information when they need it most. In summary, a comprehensive nursing strategy that develops internal locus of control, especially through powerful-other HLC, encourages family communication about cancer, improves health literacy, and can effectively reduce FoP among older spousal caregivers of cancer patients. This approach is underpinned by the recognition that enhancing control, communication, and health literacy are key to supporting the psychological well-being of caregivers and improving cancer care outcomes. Implications for practice and research The multidimensional (individual, family, and societal) factors influencing FoP in older spousal caregivers of patients with cancer were clarified to provide a theoretical basis and new targets for tailored clinical intervention. Some misconceptions in daily life were corrected. This study revealed that health education for spouses of cancer patients should be strengthened by authoritative figures such as medical staff, and communication between family members about cancer should be strengthened instead of blindly avoiding it. Actively obtaining disease-related information in various ways is beneficial for relieving the psychological pressure on older cancer patients and their spouses. Declarations Availability of data and materials All data generated or analyzed during this study are included in this published article. Authors ' contributions Ruirui Qiu, Yuli Li, and Junhua Sun participated in the study design. Ruirui Qiu, Qingyan Zhou, and Chunyu Ren collected the patient data. Yuli Li and Ruirui Qiu performed the data analysis. Ye Lan provided instructions on how to translate this article. The original manuscript was drafted by Ruirui Qiu and Yaoyi Pan and reviewed by Yuli Li, Ye Lan, Qingyan Zhou, Chunyu Ren, and Junhua Sun. All authors approve the final manuscript as submitted and agree to be responsible for all aspects of the work. Ethical considerations In this study, all methods were performed by the relevant guidelines and regulations. The study was approved by the Ethics Committee of the Second Hospital of Shandong University (approval number: KYLL2024468）. All procedures were by the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration. The data was collected after informed consent and written consent were obtained from each participant. Competing interests The authors declare no competing interests. Funding This study did not receive any funding in any form. Acknowledgments The authors thank the participants in this study, as well as the hospitals, for their time and dedication. We thank LetPub (www.letpub.com.cn) for its linguistic assistance during the preparation of this manuscript. Consent for publication Not applicable. References Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A: Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries . CA Cancer J Clin 2024, 74 (3):229-263.https://doi.org/10.3322/caac.21834. 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Zhang Y: Associations of illness perception, mindfulness with fear of cancer recurrence among breast cancer patients and their spouses: the mediating role of family avoidance cancer communication about cancer . Shandong University; 2022. Dogonchi M, Mohammadzadeh F, Moshki M: Investigating the relationship between health locus of control and health behaviors: A systematic review . The Open Public Health Journal 2022, 15 (1).https://doi.org/10.3389/fcdhc.2022.1044005. Rodriguez A, Delbourgo Patton C, Stephenson-Hunter C: Impact of Locus of Control on Patient-Provider Communication: A Systematic Review . J Health Commun 2023, 28 (3):190-204. https://doi.org/10.3389/fcdhc.2022.1044005. Gordon NP, Crouch E: Digital Information Technology Use and Patient Preferences for Internet-Based Health Education Modalities: Cross-Sectional Survey Study of Middle-Aged and Older Adults With Chronic Health Conditions . JMIR Aging 2019, 2 (1):e12243.https://doi.org/10.2196/12243. Norman CD, Skinner HA: eHealth Literacy: Essential Skills for Consumer Health in a Networked World . J Med Internet Res 2006, 8 (2):e9.https://doi.org/10.2196/jmir.8.2.e9. Berkman ND, Davis TC, McCormack L: Health literacy: what is it? Journal of health communication 2010, 15 (S2):9-19.https://doi.org/10.3322/caac.2183410.1080/10810730.2010.499985. Halbach SM, Ernstmann N, Kowalski C, Pfaff H, Pförtner TK, Wesselmann S, Enders A: Unmet information needs and limited health literacy in newly diagnosed breast cancer patients over the course of cancer treatment . Patient Education and Counseling 2016, 99 (9):1511-1518.https://doi.org/10.1016/j.pec.2016.06.028. Jia Y: Correlation study of social support, perception control, health literacy and self-management in patients with heart disease◻◻ . 2020.https://doi.org/10.27368/d.cnki.gtzyy.2020.000449. Zimmermann T, Alsleben M, Heinrichs N: [Fear of progression in partners of chronically ill patients] . Psychother Psychosom Med Psychol 2012, 62 (9-10):344-351.https://doi.org/10.27368/d.cnki.gtzyy.2020.00044910.1055/s-0032-1321880. Kendall M G, Multivariate analysis, Hodder Arnold, New York (NY), 1975. Wu Q: The status research and study on Fear of Progression of Primary Liver Cancer patients and their spouses . The Second Military Medical University; 2016. Herschbach P, Berg P, Waadt S, Duran G, Engst-Hastreiter U, Henrich G, Book K, Dinkel A: Group psychotherapy of dysfunctional fear of progression in patients with chronic arthritis or cancer . Psychother Psychosom 2010, 79 (1):31-38.https://doi.org/10.1159/000254903. Ip WY, Martin CR: The Chinese version of the multidimensional health locus of control scale form C in pregnancy . J Psychosom Res 2006, 61 (6):821-827.https://doi.org/10.1016/j.jpsychores.2006.08.011. Zhang Xy, Xie Zh, Li Yy, Li P: Sinicization and reliability and validity evaluation of family avoidance of Cancer communication Scale . journal of nursing science(Chinese journal) 2022, 37 (07):9-12 Li S, Cui G, Xu H: Revision and validation of the brief health Literacy assessment Scale for the elderly . Journal of Central South University (Medical) 2023, 48 (01):123-129. Nie X, Li Y, LiLi: Methods of statistical analysis of health literacy monitoring data of Chinese residents in 2012 . Chinese health education(Chinese journal) 2014, 30 (02):178-181.https://doi.org/10.16168/j.cnki.issn.1002-9982.2014.02.021. Xiong H, Zhang J, Ye B, Zheng X, Sun P: Model analysis of the effects of common method variance and its statistical control pathways . Advances in Psychological Science(Chinese journal) 2012, 20 (05):757-769.https://doi.org/10.3724/SP.J.1042.2012.00757. Hu Lt, Bentler PM: Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives . Structural equation modeling: a multidisciplinary journal 1999, 6 (1):1-55.https://doi.org/10.1080/00273171.2022.2163476. Kline, Theresa JB, Psychological testing: A practical approach to design and evaluation, Sage publications, 2005. Wu LM, McGinty H, Amidi A, Bovbjerg K, Diefenbach MA: Longitudinal dyadic associations of fear of cancer recurrence and the impact of treatment in prostate cancer patients and their spouses . Acta Oncol 2019, 58 (5):708-714.https://doi.org/10.1080/0284186x.2018.1563714. Braun SE, Aslanzadeh FJ, Thacker L, Loughan AR: Examining fear of cancer recurrence in primary brain tumor patients and their caregivers using the Actor-Partner Interdependence Model . Psychooncology 2021, 30 (7):1120-1128.https://doi.org/10.1002/pon.5659. Chien CH, Chuang CK, Liu KL, Wu CT, Pang ST, Chang YH: Positive and negative affect and prostate cancer-specific anxiety in Taiwanese patients and their partners . Eur J Oncol Nurs 2018, 37 :1-11.https://doi.org/10.1016/j.ejon.2018.09.004. Hu X, Wang W, Wang Y, Liu K: Fear of cancer recurrence in patients with multiple myeloma: Prevalence and predictors based on a family model analysis . Psychooncology 2021, 30 (2):176-184.https://doi.org/10.1002/pon.5546. Lorimer SB, Sansom-Daly UM, Stech EP, Newby JM: Predictors of health anxiety in cancer patients' loved ones: A controlled comparison . Psychooncology 2020, 29 (11):1874-1882.https://doi.org/10.1002/pon.5517. Lin CR, Chen SC, Simard S, Chang JT, Lai YH: Psychometric testing of the Fear of Cancer Recurrence Inventory-caregiver Chinese version in cancer family caregivers in Taiwan . Psychooncology 2018, 27 (6):1580-1588.https://doi.org/10.1002/pon.4697. Paik JH, Ryu CG, Hwang DY: Risk factors of recurrence in TNM stage I colorectal cancer . Ann Surg Treat Res 2023, 104 (5):281-287.https://doi.org/10.4174/astr.2023.104.5.281. Nie S, Peng H, Ju Q, Liang Q, Zhang C, Qiang X, Gan Y: The Relationship Between Meaning in Life and Health Behaviors in Adults Aged 55 Years and Over During the COVID-19 Pandemic: the Mediating Role of Risk Perception and the Moderating Role of Powerful Others Health Locus of Control . Int J Behav Med 2023, 30 (3):388-397.https://doi.org/10.1007/s12529-022-10100-x. Mussie KM, Kaba M, Setchell J, Elger BS: "I Do Not Believe We Should Disclose Everything to an Older Patient": Challenges and Ethical Concerns in Clinical Decision-Making in Old-Age Care in Ethiopia . Health Care Anal 2024, 32 (4):290-311.https://doi.org/10.1007/s10728-024-00494-y. Lorini C, Buscemi P, Mossello E, Schirripa A, Giammarco B, Rigon L, Albora G, Giorgetti D, Biamonte MA, Fattorini L et al : Health literacy of informal caregivers of older adults with dementia: results from a cross-sectional study conducted in Florence (Italy) . Aging Clin Exp Res 2023, 35 (1):61-71.https://doi.org/10.1007/s40520-022-02271-0. Committee Esc-CaHCME, Association BcPCoCA-C: Multidisciplinary Criteria and Practice for Breast Cancer (2023 edition) . Chinese Journal of Cancer(Chinese journal) 2023, 33 (12):1188-1203 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Nov, 2025 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 16 Jun, 2025 Reviews received at journal 13 Jun, 2025 Reviews received at journal 08 Jun, 2025 Reviews received at journal 07 Jun, 2025 Reviewers agreed at journal 25 May, 2025 Reviewers agreed at journal 21 May, 2025 Reviewers agreed at journal 19 May, 2025 Reviewers agreed at journal 19 May, 2025 Reviewers invited by journal 19 May, 2025 Editor assigned by journal 15 May, 2025 Submission checks completed at journal 14 May, 2025 First submitted to journal 14 May, 2025 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. 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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-6533203","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":459153394,"identity":"3df830d1-d5b0-4926-868d-ac564cc33658","order_by":0,"name":"Ruirui Qiu","email":"","orcid":"","institution":"The Second Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Ruirui","middleName":"","lastName":"Qiu","suffix":""},{"id":459153395,"identity":"762a02f3-981b-4c60-a16b-02f04a293749","order_by":1,"name":"Yuli Li","email":"","orcid":"","institution":"The Second Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Yuli","middleName":"","lastName":"Li","suffix":""},{"id":459153396,"identity":"e4e31415-a3ec-405c-89ef-19b98fb0c6a2","order_by":2,"name":"Yaoyi Pan","email":"","orcid":"","institution":"Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Yaoyi","middleName":"","lastName":"Pan","suffix":""},{"id":459153397,"identity":"90ebf502-4ed3-4710-beb3-793a992a9b78","order_by":3,"name":"Lan Ye","email":"","orcid":"","institution":"The Second Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Lan","middleName":"","lastName":"Ye","suffix":""},{"id":459153399,"identity":"f48fb38e-3b39-4014-83b1-0ec2bd1ed191","order_by":4,"name":"Chunyu Ren","email":"","orcid":"","institution":"The Second Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Chunyu","middleName":"","lastName":"Ren","suffix":""},{"id":459153401,"identity":"def7ad05-0001-46ef-982f-1ca099b12db8","order_by":5,"name":"Qingyan Zhou","email":"","orcid":"","institution":"The Second Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Qingyan","middleName":"","lastName":"Zhou","suffix":""},{"id":459153402,"identity":"fb421736-9d69-4840-99ac-33056287056c","order_by":6,"name":"Junhua Sun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIie3PoY7CQBDG8d1sUszmaocAJbzBJLVNeJWuAUVSWYHoppdZAfcuyJMtJKjiESS0BmxxCAScvktb3In96fkn3zBmWf+QM87NrcbAc3tal2G8bE8+QJCAaOb317sUy2LfnnjQIybrrdoc59SvPkWHYQNNJWCmkkxRrBKHuWYVNifD3GCEJ18nOR3V95BBcdg0J0wlAHgZpVy/ksJhCIsOicQdJ8EpUiQ6JKDoJ5msHU6sWyLz1Aec+SB5CmGxl62/jI2pqvoReNPztbrd46Xnmq/m5Bf53rllWZb1pycmX04KEIVMQAAAAABJRU5ErkJggg==","orcid":"","institution":"The Second Hospital of Shandong University","correspondingAuthor":true,"prefix":"","firstName":"Junhua","middleName":"","lastName":"Sun","suffix":""}],"badges":[],"createdAt":"2025-04-26 07:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6533203/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6533203/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-025-04035-3","type":"published","date":"2025-11-10T15:58:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83282330,"identity":"b442181c-eb2f-4c12-ba5b-83280207be1e","added_by":"auto","created_at":"2025-05-22 10:35:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23335,"visible":true,"origin":"","legend":"\u003cp\u003eHypothetical model diagram\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6533203/v1/a655447c41f787f0ed62b34c.jpg"},{"id":83282331,"identity":"87908b93-4ecd-4d61-9f13-be7c5be79156","added_by":"auto","created_at":"2025-05-22 10:35:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":49626,"visible":true,"origin":"","legend":"\u003cp\u003eFinal structural equation model\u003c/p\u003e\n\u003cp\u003eNote: \u003csup\u003e*\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05;\u003csup\u003e **\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01, \u003csup\u003e***\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001. Control variable: TNM stage.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6533203/v1/95af772dfab5cceb389366e1.jpg"},{"id":96105232,"identity":"cfbc7c8a-04ee-4022-a1dc-9fd153b970b3","added_by":"auto","created_at":"2025-11-17 16:10:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3172875,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6533203/v1/50c81e7e-19b4-4ce1-92ea-6e8b168cea18.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors associated with the fear of disease progression in older spousal caregivers of patients with cancer: a cross-sectional study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAccording to global cancer statistics, nearly 20\u0026nbsp;million new cancer cases were diagnosed worldwide in 2022, and this number is expected to reach 35\u0026nbsp;million by 2050 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Moreover, 78% of patients with cancer are aged 60 years and older [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]; thus, older patients with cancer and their spouses constitute a large group. During the diagnosis and treatment of cancer, patients' spouses are their closest and primary social supporters, so spouses must also experience potential adverse effects and psychological distress. The negative emotions of patients with cancer are interrelated with those of their spouses and affect each other. In recent years, with improvements in diagnostic and treatment technologies, the fear of cancer recurrence and progression has become a common problem affecting patients and their families [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Fear of disease progression (FoP) refers to an individual's fear of all diseases related to their current condition. This is specifically defined as a reactive and conscious fear of the various biological, social, and psychological consequences arising from disease progression or recurrence [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Previous studies have shown that the fear of disease progression is high in both patients with cancer and their spouses [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], with some studies showing that spouses score higher in terms of FoP than do patients themselves [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. At present, the psychological interaction between patients with cancer and their spouses has become a research focus [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]; however, there is a lack of interest in psychological and influencing factors among spouses of patients with cancer. This study was conducted among a large population of older patients with cancer. The family model of predictors of fear of cancer recurrence highlights that fear in patients with cancer and their family members is affected by individual, family, and social factors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, in this study, we explored the factors influencing FoP from these perspectives. Understanding the factors influencing FoP in the spouses of patients with cancer will help to provide a theoretical basis for formulating psychological intervention measures for this population.\u003c/p\u003e \u003cp\u003eIn the face of enormous stress after a cancer diagnosis, family members often experience negative effects, depending on their own beliefs. As an attributional psychological factor, health locus of control (HLC) refers to an individual's intuition and causal beliefs about the determinants of their own health, which emphasize the degree to which an individual believes that health is controlled by internal or external factors. This can directly affect and predict whether an individual will adopt certain health behaviors [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Studies have shown that the management of individual locus of control helps develop individual potential, improve and maintain their individual positive mental state and health behaviors and is closely related to the health management of patients with cancer [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, HLC may be associated with psychological barriers related to FoP.\u003c/p\u003e \u003cp\u003eWith ongoing investigations into FoP, the scope of research has gradually expanded from a single patient to a whole group of patients and their spouses. However, in the context of cancer, patients and family members usually hide their feelings to protect each other, resulting in a lack of direct communication or limiting communication between the two parties [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This communication method, in which both parties are unwilling to openly exchange cancer-related information and feelings, is referred to as the family's avoidance of cancer communication [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Research on breast cancer indicates that communication between partners has a significant effect on spouses\u0026rsquo; FoP [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Previous studies among patients with breast cancer and their spouses have shown that family avoidance of cancer communication has a mediating role between mindfulness and fear of cancer recurrence [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Moreover, HLC is recognized as a factor affecting the development and promotion of health behaviors [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], whereas family avoidance of cancer communication is unhealthy behavior. However, little is known about the relationship between HLC and family avoidance of cancer communication. However, a previous study revealed that locus of control can impact patient\u0026ndash;provider communication [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, it is speculated that family avoidance of cancer communication may also have a mediating effect on the relationship between HLC and FoP.\u003c/p\u003e \u003cp\u003eWith the rapid development of network information technology and the use of smartphones, the internet can provide older people with a variety of online health resources and medically related information to help them manage their health and psychological problems [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Although the internet can provide resources for individuals seeking knowledge about health conditions and treatments, this does not mean that people can always use these resources correctly to help solve existing health problems [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Health literacy refers to the ability of individuals to obtain, process, and understand basic health information and services and to use such information and services to make appropriate health decisions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Studies among patients with newly diagnosed breast cancer have shown that limited health literacy is associated with greater FoP [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, the situations and psychological statuses of patients and their spouses are different. Therefore, health literacy may also be associated with the fear of disease progression among older spousal caregivers of patients with cancer.\u003c/p\u003e \u003cp\u003eWhen a patient's spouse is aware that the doctor or family and friends will have an impact on the patient\u0026rsquo;s recovery from cancer, they will actively and effectively communicate with the doctor and family to obtain health information and make correct health decisions; this can be regarded as the patient receiving external support. However, when patients have low health literacy, communication with family, doctors, or friends about health problems is ineffective. Thus, health locus of control may affect health literacy and family communication. Previous studies have shown that health literacy has a mediating effect on the relationship between perceived control and self-management [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. It is speculated that health literacy may play a mediating role in the relationship between health locus of control and fear of disease progression. Health literacy is defined by the Canadian Public Health Association as the ability of individuals to obtain, understand, evaluate, and exchange information to promote, maintain, and improve health at different times during a person's life [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Therefore, communication among family members is conducive to the acquisition of information about the disease, the evaluation of treatment effects, and making correct health-related decisions. Thus, family avoidance of cancer communication may also have an effect on health literacy.\u003c/p\u003e \u003cp\u003eIn summary, we propose the following hypothesis: family avoidance of communication about cancer and health literacy have a chain mediating effect on the relationship between the health locus of control and the fear of disease progression. A hypothesis model diagram is shown 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 Study design and participants\u003c/h2\u003e \u003cp\u003eUsing a convenience sampling method, we selected older spousal caregivers of patients with cancer who were hospitalized in the Oncology Department of two Class III Grade A hospitals in Shandong Province from December 2023 to April 2024. According to the sample size estimation method of Kendall [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], the sample size of descriptive research was 5\u0026ndash;10 times the number of variables. The four research variable scales used in this study cover a total of 8 dimensions. Considering the failure rate of 20% of the questionnaires, the sample size was estimated to be 50 to 100 cases. Thus, a total of 210 samples were collected to meet the sample size requirements.\u003c/p\u003e \u003cp\u003eThe inclusion criteria as follows: ① patients with cancer cared for by their spouses had a tumor, node, or metastasis (TNM) \u0026le;stage III; ② the spouse had an age\u0026thinsp;\u0026ge;\u0026thinsp;60 years; ③ the spouse was the primary caregiver for the patient, had at least a primary school education, and was involved in the patient's medical decision-making; ④ the spouse had no history of mental illness and spoke clearly; and ⑤ the spouse voluntarily participated in the study. ⑥ Using the Mini-Mental State Examination to screen the spouse for dementia. The exclusion criteria as follows: ① patients with cancer who had recurrence or distant metastasis; ② spouses whohad severe heart, lung, kidney or other major organ dysfunction; ③ spouses with mental or cognitive impairment or dementia; and ④ spouses with serious auditory, visual, or language barriers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Measurement\u003c/h2\u003e \u003cp\u003eWe selected scales suitable for use in older populations, which have been validated and have excellent reliability and sensitivity.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 General sociodemographic and disease survey\u003c/h2\u003e \u003cp\u003eThis survey included information about the older spousal caregivers of patients, such as sex, age, residence, educational level, occupation, family monthly income, number of children, and number of chronic diseases. Patient information included self-care ability, family history of cancer, disease duration and TNM stage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Chinese Fear of Disease Progression Questionnaire-Short-Form for Partners (FOP-Q-SF/P)\u003c/h2\u003e \u003cp\u003eThe Chinese version of the FOP-Q-SF/P [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] was used to assess the level of FoP in a patient's spouse. The FOP-Q-SF/P includes two dimensions, physical health and social family function and has a total of 12 items. The scale is scored on a 5-point Likert scale. The minimum score is 12 and the maximum score is 60, with higher scores indicating greater fear of disease progression. A score of \u0026ge;\u0026thinsp;34 is considered a borderline score related to mental dysfunction owing to FoP [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The scale has good reliability and validity, and the Cronbach's α coefficient in the present study was 0.89.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Form C of the Multidimensional Health Locus of Control (MHLC-C)\u003c/h2\u003e \u003cp\u003eThe Chinese version of the MHLC-C was used to measure sources of control in patients aged 18 years and older in medical settings [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The MHLC-C scale contains a total of 18 items, with three main subscales\u0026mdash;internal health locus of control (HLC), chance HLC and powerful-others HLC (PHLC). Each item uses a 6-point Likert scale. The score of each subscale is the sum of the scores of the items under that subscale. The highest score among the three subscales determines the patients' type of health locus of control. The Cronbach's α coefficient in this study was 0.86.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.2.4 Family Avoidance of Communication about Cancer Scale (FACC)\u003c/h2\u003e \u003cp\u003eThe Chinese version of the FACC was used to measure the perceived degree of openness or avoidance of family cancer-related communication among patients with breast cancer and their family caregivers [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The scale has five items and uses a 5-point Likert scale. For each item, the spouse selects the number that best matches their disease communication situation during the past month. The original total scale score is the average of the five items. The original score and total score of the scale are subsequently converted into a standard score ranging from 0 to 100 points. The standard score is calculated as (original score\u0026thinsp;\u0026minus;\u0026thinsp;1)/4\u0026times;100, with higher scores indicating more family avoidance of cancer-related communication. The Cronbach's α coefficient of the scale in this study is 0.90.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.2.5 Brief Health Literacy Assessment Scale\u003c/h2\u003e \u003cp\u003eThe Chinese mainland version of the Brief Health Literacy Assessment Scale was used to evaluate self-perceived health literacy in older patients [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The scale includes two dimensions and 10 items that use a 5-point Likert scale. The total score ranges from 10 to 50 points, with higher scores indicating better health literacy. According to the criteria developed by National Health Literacy Monitoring [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], 80% of the scale score (40 points) was taken as the threshold for qualified health literacy in this study, with a score of \u0026ge;40 points indicating qualified health literacy. In this study, the Cronbach's α coefficient of the scale was 0.96.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Procedure\u003c/h2\u003e \u003cp\u003eA face-to-face paper questionnaire survey was conducted in this study. The purpose and importance of the study were explained to participants before they completed the questionnaire, after the consent of patients\u0026rsquo; spouses was obtained. If participants could not complete the form independently, the investigators read each item to them and completed the questionnaire on the basis of the participants\u0026rsquo; responses. Questionnaires were distributed and collected on the spot, and missing items were checked to ensure data integrity. Therefore, all the collected data had no missing data. Data were entered by two individuals. A total of 230 questionnaires were distributed and 210 valid questionnaires were collected, resulting in an effective recovery rate of 91.30%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Ethical considerations\u003c/h2\u003e \u003cp\u003e In this study, all methods were performed by the relevant guidelines and regulations. The study was approved by the Ethics Committee of the Second Hospital of Shandong University (approval number: KYLL2024468). All procedures were by the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration. The data was collected after informed consent and written consent were obtained from each participant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e \u003cp\u003eIBM SPSS 24.0 was used for the data analysis. Categorical data are presented as frequencies and percentages, and continuous data are presented as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations. Univariate analysis, Pearson correlation analysis, and multiple linear regression analysis were used to determine the variables included in the structural equation model. AMOS 26.0 was used to construct the structural equation model and the bootstrap method was used to test the mediating effect. A P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Sociodemographic characteristics\u003c/h2\u003e \u003cp\u003eIn this study, most participants were aged 60\u0026ndash;69 years. Patients with cancer were mainly from rural areas, had a junior high school education, worked in farming, and had medical insurance for residents. The average disease duration of the patients was 12.68\u0026thinsp;\u0026plusmn;\u0026thinsp;19.57 months. For details, see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; the upper part shows the information of the spouses of the cancer patients, and the lower part shows the information of the cancer patients.\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\u003eSociodemographic characteristics and univariate analysis results (N\u0026thinsp;=\u0026thinsp;210)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFoP score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eLSD-t\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe older spousal caregivers of patients\u003c/b\u003e\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 \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e34.58\u0026thinsp;\u0026plusmn;\u0026thinsp;9.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e35.96\u0026thinsp;\u0026plusmn;\u0026thinsp;9.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e35.18\u0026thinsp;\u0026plusmn;\u0026thinsp;9.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e35.29\u0026thinsp;\u0026plusmn;\u0026thinsp;10.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e39.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e①Rural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e36.17\u0026thinsp;\u0026plusmn;\u0026thinsp;11.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e②\u0026gt;③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e②Town\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e36.74\u0026thinsp;\u0026plusmn;\u0026thinsp;7.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e③City\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e32.94\u0026thinsp;\u0026plusmn;\u0026thinsp;8.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e32.38\u0026thinsp;\u0026plusmn;\u0026thinsp;12.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e35.61\u0026thinsp;\u0026plusmn;\u0026thinsp;10.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior high school or technical secondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e36.89\u0026thinsp;\u0026plusmn;\u0026thinsp;9.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior college or higher vocational school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e33.68\u0026thinsp;\u0026plusmn;\u0026thinsp;7.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor degree or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e33.86\u0026thinsp;\u0026plusmn;\u0026thinsp;7.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocational institution\u003c/p\u003e \u003cp\u003eor state-owned enterprise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e34.02\u0026thinsp;\u0026plusmn;\u0026thinsp;9.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate sector\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e34.35\u0026thinsp;\u0026plusmn;\u0026thinsp;9.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e35.07\u0026thinsp;\u0026plusmn;\u0026thinsp;9.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e36.78\u0026thinsp;\u0026plusmn;\u0026thinsp;10.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e34.85\u0026thinsp;\u0026plusmn;\u0026thinsp;10.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily monthly income(RMB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e35.21\u0026thinsp;\u0026plusmn;\u0026thinsp;11.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1000\u0026ndash;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e36.36\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5000\u0026ndash;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e33.20\u0026thinsp;\u0026plusmn;\u0026thinsp;7.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e34.71\u0026thinsp;\u0026plusmn;\u0026thinsp;8.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e34.09\u0026thinsp;\u0026plusmn;\u0026thinsp;8.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e36.41\u0026thinsp;\u0026plusmn;\u0026thinsp;10.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e31.40\u0026thinsp;\u0026plusmn;\u0026thinsp;8.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e35.56\u0026thinsp;\u0026plusmn;\u0026thinsp;10.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e33.60\u0026thinsp;\u0026plusmn;\u0026thinsp;8.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e37.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe patients\u003c/b\u003e\u003c/p\u003e \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 \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-care ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e①Cannot care for self\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e35.91\u0026thinsp;\u0026plusmn;\u0026thinsp;10.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e②\u0026gt;③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e②Partial self-care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e38.51\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e③Full self-care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e34.30\u0026thinsp;\u0026plusmn;\u0026thinsp;9.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily history of cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e34.99\u0026thinsp;\u0026plusmn;\u0026thinsp;10.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e36.39\u0026thinsp;\u0026plusmn;\u0026thinsp;8.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNM staging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e①I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e30.78\u0026thinsp;\u0026plusmn;\u0026thinsp;7.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e①\u0026lt;②\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e②II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e37.29\u0026thinsp;\u0026plusmn;\u0026thinsp;8.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e①\u0026lt;③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e③III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e36.53\u0026thinsp;\u0026plusmn;\u0026thinsp;10.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e①\u0026lt;④\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e④Unclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e37.39\u0026thinsp;\u0026plusmn;\u0026thinsp;11.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\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=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Univariate analysis of the fear of disease progression\u003c/h2\u003e \u003cp\u003eThe results of the univariate analysis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) revealed that the fear of disease progression varied in terms of residence, self-care ability, and TNM stage. Moreover, post hoc multiple comparisons revealed that FoP among town dwellers was greater than that among city dwellers and that the level of partial self-care was greater than that of complete self-care. TNM stage I was lower than the other phases were.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Correlation analysis among the study variables\u003c/h2\u003e \u003cp\u003eThe score for FoP was 35.21\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79. Pearson correlation analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, end of text) showed that health locus of control, powerful-others HLC and health literacy was significantly negatively correlated with fear of disease progressio\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations among health locus of control, family avoidance of cancer communication, health literacy and FoP (\u003cem\u003er\u003c/em\u003e, N\u0026thinsp;=\u0026thinsp;210)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.Fear of disease progression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.21\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\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 \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.Physical health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.34\u0026thinsp;\u0026plusmn;\u0026thinsp;6.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.94\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.Social family function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.71\u0026thinsp;\u0026plusmn;\u0026thinsp;3.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.81\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.56\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.Health locus of control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.10\u0026thinsp;\u0026plusmn;\u0026thinsp;13.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.17\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.16\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.Internal locus of control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.72\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.Powerful-others HLC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.76\u0026thinsp;\u0026plusmn;\u0026thinsp;8.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.34\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.30\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.27\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.76\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.23\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.Chance HLC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.62\u0026thinsp;\u0026plusmn;\u0026thinsp;5.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.69\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.57\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.15\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8.Family avoidance of communication about cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.60\u0026thinsp;\u0026plusmn;\u0026thinsp;29.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.32\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.22\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.24\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.34\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9.Health literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.38\u0026thinsp;\u0026plusmn;\u0026thinsp;8.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.31\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.28\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.25\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.41\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.24\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.41\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.18\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-0.28\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10.Health information literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.36\u0026thinsp;\u0026plusmn;\u0026thinsp;5.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.32\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.29\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.26\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.41\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.24\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.42\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.17\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-0.28\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.97\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11.Communication literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.02\u0026thinsp;\u0026plusmn;\u0026thinsp;3.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.27\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.24\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.22\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.36\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.22\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.36\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.16\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-0.26\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.94\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.84\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003eNote: \u003csup\u003e*\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e**\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01. M\u0026thinsp;=\u0026thinsp;mean, SD\u0026thinsp;=\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe FoP score was 35.21\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79. Pearson correlation analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, end of the text) revealed that health locus of control, powerful-other HLC and health literacy were significantly negatively correlated with fear of disease progression (r=-0.17, P0.05; r=-0.34, P\u0026lt;0.01; and r=-0.31, P\u0026lt;0.01, respectively), whereas family avoidance of communication about cancer was significantly positively related to fear of disease progression (r\u0026thinsp;=\u0026thinsp;0.32, P\u0026lt;0.01).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Multiple linear regression analysis of fear of disease progression\u003c/h2\u003e \u003cp\u003eMultiple linear regression analysis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) was used to analyze factors related to FoP with the significant variables as dependent variables according to univariate analysis and correlation analysis. Model 1 included residence, self-care ability, and TNM stage, and the adjusted \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e was 0.09(P\u0026lt;0.001). Model 2 was further adjusted for powerful-other HLC and family avoidance of cancer communication and health literacy, and the adjusted \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e was 0.22 (P\u0026lt;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of multivariate linear analysis (N\u0026thinsp;=\u0026thinsp;210)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence (town)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence (city)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;1.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNM stage ΙΙ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.31\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.96\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNM stage ΙΙΙ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.33\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.01\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNM stage unclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.59\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth literacy\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 \u003cp\u003e\u0026minus;0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;2.74\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily avoidance of communication about cancer\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 \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.57\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePowerful-others HLC\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 \u003cp\u003e\u0026minus;0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;2.10\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.12\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e0.26\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjusted \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.09\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e0.22\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e3.97\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e6.90\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: \u003csup\u003e*\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e**\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01; \u003csup\u003e***\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e3.5 Chain mediating effect of family avoidance of cancer communication and health literacy on the relationship between health locus of control and fear of disease progression\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe Harman single-factor test method [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] was used. The test results revealed that there were 8 factors with eigenvalues greater than 1, and the first factor explained 24.88% of the variance, which was less than the critical standard of 40%, indicating that there was no obvious common method deviation in the data of this study.\u003c/p\u003e \u003cp\u003eIn this study, TNM stage was used as a control variable according to the multiple linear regression analysis results; powerful-other HLC subscale of health locus of control was used as the independent variable; family avoidance of communication about cancer and health literacy were used as the mediating variables; and FoP was used as the dependent variable. The final structural equation model (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) with the maximum likelihood method was acceptable, with a good model fit index: χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;0.264\u0026thinsp;\u0026lt;\u0026thinsp;5.000, CFI\u0026thinsp;=\u0026thinsp;1.000\u0026thinsp;\u0026gt;\u0026thinsp;0.900, RMSEA\u0026thinsp;=\u0026thinsp;0.000\u0026thinsp;\u0026lt;\u0026thinsp;0.080, NFI\u0026thinsp;=\u0026thinsp;0.997\u0026thinsp;\u0026gt;\u0026thinsp;0.900, AGFI\u0026thinsp;=\u0026thinsp;0.991\u0026thinsp;\u0026gt;\u0026thinsp;0.900 [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The results of the mediation effect test are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMediation effect test results\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\"\u003e \u003cp\u003ePath of influence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEffect size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProportion of relative effects (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBoot standard error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.51\u0026thinsp;~\u0026thinsp;\u0026minus;\u0026thinsp;0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.36\u0026thinsp;~\u0026thinsp;\u0026minus;\u0026thinsp;0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirect effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.26\u0026thinsp;~\u0026thinsp;\u0026minus;\u0026thinsp;0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePowerful-others HLC\u0026rarr;Family avoidance of communication about cancer\u0026rarr;Fear of disease progression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.15\u0026thinsp;~\u0026thinsp;\u0026minus;\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePowerful-others HLC\u0026rarr;Health literacy\u003c/p\u003e \u003cp\u003e\u0026rarr;Fear of disease progression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.14\u0026thinsp;~\u0026thinsp;\u0026minus;\u0026thinsp;0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePowerful-others HLC\u0026rarr;Family avoidance of communication about cancer\u0026rarr;Health literacy\u0026rarr;Fear of disease progression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.03\u0026thinsp;~\u0026thinsp;\u0026minus;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study aimed to trace the level of FoP among older spousal caregivers of patients with cancer and the mediating effects of family avoidance of cancer communication and health literacy on the relationship between HLC and FoP. Studies have begun to focus on the FoP of the spouses of cancer patients [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] and one has shown a significant correlation between age and caregiver FoP [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. However, older spouse caregivers of cancer patients continue to receive less attention. The present study explored potential mechanisms affecting FoP from multiple perspectives among older spousal caregivers of patients with cancer. The results suggested that family avoidance of communication about cancer could positively affect the FoP of older spousal caregivers, whereas HLC and health literacy had negative impacts on the FoP of older spousal caregivers. Therefore, this study provides ideas for reducing the FoP of older spousal caregivers, emphasizing the role of HLC, family avoidance of communication, health literacy and other associated factors.\u003c/p\u003e \u003cp\u003eAs an important factor affecting life expectancy, the recurrence and metastasis of cancer have yet to be conquered [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], so disease progression remains a concern for cancer patients and their caregivers. The results of this study revealed that the level of FoP among older spousal caregivers of patients with cancer exceeded normal and that these patients had dysfunction in FoP (35.21\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79\u0026thinsp;\u0026ge;\u0026thinsp;34), which is similar to the findings of previous studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. A high level of FoP among older spousal caregivers impacts their physical and mental health, reduces their ability to provide care and affects their and patients\u0026rsquo; quality of life [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The results revealed that the current status of FoP among older spousal caregivers of patients with cancer was not encouraging and required urgent attention and effective help from health care professionals.\u003c/p\u003e \u003cp\u003eMoreover, the present study identified several sociodemographic characteristics associated with older spousal caregivers\u0026rsquo; FoP, including residence, self-care ability, and TNM stage. While this study failed to find a significant relationship between age and FoP, one conjecture about this phenomenon is that all those included in this study were over 60 years of age, which is not a large span. In this study, older spousal caregivers living in towns had greater FoP than did those living in cities. This might be because town residents are under more financial pressure, such as insurance, and often have to leave their place of living to take care of patients in hospitals, where tertiary hospitals are often in the city. This study revealed a statistically significant impact of TNM stage, with older spousal caregivers having the lowest levels of FoP for patients in TNM stage I patients. This may be related to the medical characteristics of TNM stage I patients, with a low recurrence rate of cancer [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], which buffers FoP for older spousal caregivers.\u003c/p\u003e \u003cp\u003eThe HLC measurements indicated that older spousal caregivers tend to be PHLCs, who believe that health relies on the guidance and care of authorities, echoing previous research showing that older adults are more inclined to trust powerful others[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The reason may be that in the face of the significant event of their partner's cancer, older spousal caregivers generally believe that they are unable to change the patient's state of illness on their own and therefore place the patient's restoration of health in the hands of health care professionals and become physically and psychologically more reliant on their help and support. Additionally, the correlation analysis further confirmed that HLC and PHLC were negatively correlated with FoP. Specifically, the stronger older spousal caregivers\u0026rsquo; perceptions of the source of control over their health event are, the lower their FoP may be. Older spousal caregivers were more trusting of health care professionals, making it more effective to change their adverse perceptions, reduce their negative emotions and decrease FoP through health care professional interventions.\u003c/p\u003e \u003cp\u003eIn this study, PHLC was found to have a significantly negative effect on family avoidance of communication about cancer, whereas family avoidance of communication about cancer was found to have a positive influence on FoP in older spouse caregivers. Furthermore the mediating role of family avoidance of communication about cancer between PHLC and FoP was also illustrated. These findings suggeste that as older spouse caregivers tend to PHCL more, they might be more willing to discuss things related to cancer, which could lead to a reduction in their fear of cancer progression. Effective communication has been identified as a key factor in managing family tension and regulating coping mechanisms [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], which is particularly relevant for older spousal caregivers. Therefore, effective interventions are important to promote older spouse caregivers\u0026rsquo; PHLC, allowing them to communicate freely with patients to overcome communication barriers and ultimately facilitating their freedom from the fear of disease progression.\u003c/p\u003e \u003cp\u003eIn the present study, the health literacy of older spouse caregivers was inadequate, which was consistent with the results of a prior report [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Lorini et al. also confirmed higher rates of inadequate health literacy in older spousal caregivers with dementia. In addition, this study revealed that health literacy was positively affected by PHLC but could negatively predict the FoP of older spouse caregivers. Moreover, this study substantiated the mediating role of health literacy in the relationship between PHLC and FoP in older spouse caregivers. This might be explained by the fact that older spouse caregivers in PHLC are more trusting of health care professionals, which prompts them to follow medical advice and have better communication literacy, which in turn helps to increase their acceptance of information about cancer, reduces their psychological stress, and improves their physical health.\u003c/p\u003e \u003cp\u003eThe present study further confirmed that the relationship between PHLC and FoP was serially mediated by family avoidance of communication about cancer and health literacy. Those with high PHLC tended to attribute their health status to powerful others, have good compliance, tend not to avoid or minimize the behavior of discussing cancer-related information and feelings, access more health information and apply it to themselves and patients, thus reducing the fear of cancer progression. With improvements in cancer treatment technology and increased survival [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], patients need to undergo a long course of treatment and recovery, and their caregivers also have long periods of care. According to these findings, during this long period of fighting cancer, it is essential that older spousal caregivers are empowered with PHLC, believe in health care professionals and are more willing to communicate with patients about cancer to understand the feelings and thoughts of both parties. Health care professionals also need to be clear about the needs of older spousal caregivers and provide guidance and health information when they need it most.\u003c/p\u003e \u003cp\u003eIn summary, a comprehensive nursing strategy that develops internal locus of control, especially through powerful-other HLC, encourages family communication about cancer, improves health literacy, and can effectively reduce FoP among older spousal caregivers of cancer patients. This approach is underpinned by the recognition that enhancing control, communication, and health literacy are key to supporting the psychological well-being of caregivers and improving cancer care outcomes.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplications for practice and research\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe multidimensional (individual, family, and societal) factors influencing FoP in older spousal caregivers of patients with cancer were clarified to provide a theoretical basis and new targets for tailored clinical intervention. Some misconceptions in daily life were corrected. This study revealed that health education for spouses of cancer patients should be strengthened by authoritative figures such as medical staff, and communication between family members about cancer should be strengthened instead of blindly avoiding it. Actively obtaining disease-related information in various ways is beneficial for relieving the psychological pressure on older cancer patients and their spouses.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e'\u003cstrong\u003e\u0026nbsp;contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRuirui Qiu, Yuli Li, and Junhua Sun participated in the study design. Ruirui Qiu, Qingyan Zhou, and Chunyu Ren collected the patient data. Yuli Li and Ruirui Qiu performed the data analysis. Ye Lan provided instructions on how to translate this article. The original manuscript was drafted by Ruirui Qiu and Yaoyi Pan and reviewed by Yuli Li, Ye Lan, Qingyan Zhou, Chunyu Ren, and Junhua Sun. All authors approve the final manuscript as submitted and agree to be responsible for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, all methods were performed by the relevant guidelines and regulations. The study was approved by the Ethics Committee of the Second Hospital of Shandong University (approval number: KYLL2024468）. All procedures were by the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration. The data was collected after informed consent and written consent were obtained from each participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding in any form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the participants in this study, as well as the hospitals, for their time and dedication. We thank LetPub (www.letpub.com.cn) for its linguistic assistance during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A: \u003cstrong\u003eGlobal cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries\u003c/strong\u003e. \u003cem\u003eCA Cancer J Clin \u003c/em\u003e2024, \u003cstrong\u003e74\u003c/strong\u003e(3):229-263.https://doi.org/10.3322/caac.21834.\u003c/li\u003e\n\u003cli\u003eMiller KD, Nogueira L, Devasia T, Mariotto AB, Yabroff KR, Jemal A, Kramer J, Siegel RL: \u003cstrong\u003eCancer treatment and survivorship statistics, 2022\u003c/strong\u003e. \u003cem\u003eCA Cancer J Clin \u003c/em\u003e2022, 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However, there is a lack of attention given to the influencing factors of fear of disease progression among older spousal caregivers of patients with cancer.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study followed a cross-sectional design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 210 older spousal caregivers of patients with cancer were eligible to complete the general sociodemographic and disease questionnaire, the Chinese version of the Fear of Disease Progression Questionnaire-Short-Form for Partners, Form C of the Multidimensional Health Locus of Control Scale, the Family Avoidance of Communication about Cancer Scale, and the Brief Health Literacy Assessment. The data were analyzed via univariate analysis, Pearson correlation analysis, multiple linear regression analysis, structural equation modeling, and a bootstrap mediation effect test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe older spousal caregivers of patients with cancer had high total scores for fear of disease progression (35.21±9.79). Powerful-other health locus of control and health literacy were significantly negatively correlated with fear of disease progression, respectively(P\u0026lt;0.01), whereas family avoidance of communication about cancer was significantly positively correlated with fear of disease progression (P\u0026lt;0.01). Moreover, family avoidance of communication about cancer and health literacy had a chain mediating effect between powerful-other health locus of control and fear of disease progression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFear of disease progression among older spousal caregivers of patients with cancer can be reduced by the use of nursing strategies to control available sources, especially the powerful-other health locus of control, encouraging family communication about cancer, and improving health literacy.\u003c/p\u003e","manuscriptTitle":"Factors associated with the fear of disease progression in older spousal caregivers of patients with cancer: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-22 10:35:27","doi":"10.21203/rs.3.rs-6533203/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-16T07:19:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-13T09:31:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-09T00:38:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-07T10:01:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285476126259142546306733208445311587943","date":"2025-05-25T08:25:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122532520785047828750476443101943205121","date":"2025-05-21T09:03:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124233764434297013668260334768012839565","date":"2025-05-19T07:00:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225506629790664987771890561021920934042","date":"2025-05-19T06:29:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-19T06:23:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-15T08:07:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-15T02:30:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-05-15T02:29:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8a0ba602-2565-4507-a5f1-8431c6b738cb","owner":[],"postedDate":"May 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:05:50+00:00","versionOfRecord":{"articleIdentity":"rs-6533203","link":"https://doi.org/10.1186/s12912-025-04035-3","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2025-11-10 15:58:17","publishedOnDateReadable":"November 10th, 2025"},"versionCreatedAt":"2025-05-22 10:35:27","video":"","vorDoi":"10.1186/s12912-025-04035-3","vorDoiUrl":"https://doi.org/10.1186/s12912-025-04035-3","workflowStages":[]},"version":"v1","identity":"rs-6533203","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6533203","identity":"rs-6533203","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}