사회적 자본이 암 환자 삶의 질에 미치는 영향

Abstract

Recently, people began to define the difficulty related to cancer patients' economic burden as an independent concept of the financial toxicity of cancer. Besides, they started to study the properties of financial toxicity and its measurement methods, differentiating several distinctive financial toxicity areas. Financial toxicity is related to patient treatment. It becomes clear that financial toxicity is now an independent factor affecting the cancer patients’ life quality as part of the life change the cancer causes. Many advanced countries recognized the importance of financial toxicity earlier and proposed a model to explain cancer patients’ life quality in terms of financial toxicity. However, in Korea, few studies explain the cancer patients’ life quality using the effect of direct and indirect treatment costs. Therefore, to understand domestic cancer patients' life quality more, it is necessary to study their financial toxicity. Besides, previous researches have mainly focused on a medical approach in the fields of medicine and nursing. Thus, it is desirable to perform a social welfare study in the sense of a psycho-social approach. In this study, 250 questionnaires were distributed by mail or in-person to cancer patients who were undergoing inpatient or outpatient treatment at cancer specialty hospitals in the Yeong-Honam region, and 230 questionnaires were collected. Among them, 224 copies were used for analysis, excluding six copies of a low response rate. For the analysis, five questions were presented, and a total of 20 hypotheses were established and verified. The study results are summarized as follows. First, regarding research subjects, female patients were 61.6%, more than male patients. The average age was 62.3 years, and 137 of the 224 subjects were aged 60 or older. Among the subjects, 63.8% had a spouse, and 58.5% were unemployed, more than half. More than half of the eligible respondents answered a monthly income of less than two million Korean won, and 62.1% had private insurance support. Breast cancer was the most common cancer type, and Stage 2 was most common at 29.9%. 12.1% did not know the stages of their diseases. More than 40% of the patients were with a prevalence period of 3 years or more after diagnosis. Besides, 62.5% had comorbid diseases. Most patient's named chemotherapy as the treatment type when multiple responses were allowed. Most of them were able to behave to some extent. Second, the characteristics of the major variables were as follows. The cancer patients’ average social capital was 1.13, out of the total score of 2.94, and the standard deviation was .75. In the sub-domain, the average of bonded social capital was 1.31, higher than the overall average of 1.13. The average of bridged social capital was .84, lower than the overall average. The financial toxicity of cancer patients was 2.46 out of the total 4 points, and the standard deviation was .90. In the sub-domain, psychological response (average 2.57, standard deviation .95) was higher than physical cost (average 2.32, standard deviation 1.11). It shows that the psychological stress caused by cancer treatment make the financial toxicity of cancer patients severer than the actual cost of cancer treatment. The cancer patients’ life quality was 1.95 out of the total score of 4.22, and the standard deviation was .89. By sub-domain, it appeared in the order of social and family areas (average 2.07), body areas (average 2.04), emotional areas (average 1.97), and functional areas (average 1.68). In the functional area, which is to evaluate the quality of work household work, or leisure time, patients have limitations and restrictions, and their life quality was evaluated as the lowest. Third, according to the general characteristics, the differences in measurement variables are as follows. Every demographic characteristic, such as gender, age, education, spouse, religion, occupation, monthly income, medical security, and private insurance support (p. <.001), showed significant differences in life quality. In the medical characteristics, there were significant differences in quality of life in cancer types and stage, metastasis, comorbid diseases, and ECOG (p<.001). When examining the level of social capital, there were significant differences in all characteristics such as gender, age, education, spouse, religion, occupation, monthly income, medical security, and private insurance support (p<.001). Medical characteristics also showed statistically significant differences depending on cancer type, stage, post-diagnosis period, metastasis experience, co-morbidity, surgery and other herbal alternatives among treatment types, and ECOG (p<.001). In the case of financial toxicity, there was a significant difference in the 70s or older and the 40s or younger (p<.05), with the educational background less than high school graduates and higher than college degrees (p<. .001), with no spouse (p<.001), with no religion (p<.05), with no job (p<.001), in case of medical care patient (p<.001), if no private insurance support (p<.001), and in the case of income less than 1 million won (p<.001), when compared to other income groups. In the case of medical characteristics, the financial toxicity was different in carcinoma (p<.05), stage (p<.01), metastasis (p<.01), and ECOG (p<.001). On the other hand, the financial toxicity was higher as the stage is higher, with metastatic experience, and as behavior is more difficult. In this study, the research hypotheses for direct effects, indirect effects through parameters, and moderating effects among variables in the structural model were verified. Specifically, a total of 20 research hypotheses as follows were tested: First, the direct effects of social capital on financial toxic physical costs, psychological responses, and quality of life; Second, direct effects of physical cost and psychological response on quality of life; Third, the indirect effects of social capital on life quality and each sub-domain of life quality, as mediated by physical costs and psychological reactions; Fourth, the moderating effect of income between social capital and financial toxicity, social capital and life quality, financial toxicity and life quality. Among these, 16 hypotheses were supported, and 4 hypotheses were rejected. The detailed analysis results are as follows. First, the fit of the final research model with social capital as an independent variable, physical cost and psychological response as a parameter, life quality as a dependent variable, and income as a moderating variable was appropriate with χ² value of 190.142 (df=71, P=.000), CFI of .925, TLI of .904, RMSEA of .087, and SRMR of .060. Second, investigating the analysis results of the direct effect between the major variables, social capital (β=.66, t=6.27) and psychological responses (β=-.30, t=-2.88), were found to have a significant effect on the cancer patients’ life quality, but the physical cost (β=.02, The effect of t=.22) on the life quality of cancer patients was not statistically significant. Third, the results of the analysis on the mediating effect of financial toxicity indicated that physical cost plays a partial moderating role in the relationship between social capital's impact on the cancer patients’ life quality. For the ‘social capital → physical cost → life quality’ path, the indirect effect of the physical cost was .071 (p<.05), and the confidence interval was statistically significant as .019~.133. Furthermore, 'social capital → life quality· social and family domain' (p=.003, confidence interval .081~.239) and 'social capital → life quality in functional domain' (p=.039, confidence interval .003~.142) show that physical cost plays a statistically significant mediating role. Also, from the perspective of social capital’s effect on the cancer patients’ life quality, psychological responses were found to play a partial mediating role. Fourth, income has a statistically significant moderating effect regarding the impact of social capital on the quality of life (R² change of .026, p=.002), social capital and physical cost (R² change of .101, p=.000), social capital and psychological response (R² change of .016, p=.038), and physical cost and cancer patients’ life quality (R² change of .271, p=.004). However, for psychological response and quality of life (R² change of .004, p=.271), the income-regulating effect was not statistically significant. There are many ways to address the financial toxicity which cancer patients suffer from, such as the help of friends and relatives, insurance, etc. However, social capital has a direct effect on the broader range than these helps. Therefore, this study empirically verified the mediating effect of social capital in the relationship between financial toxicity and life quality in cancer patients. The study results can be used as data for promoting social welfare interest in cancer patients' life quality, leading to a practical and institutional consensus to prevent deterioration of their life quality.