Emerging From the “Ku:” Fluctuating in Adjusting With Breast Cancer—A Post-Traumatic Growth Theory Situated Within Chinese Culture

Abstract

This purpose of the study was to construct a model (theory) to understand Chinese women’s adjustment process in living with breast cancer. A constructivist grounded theory method was adopted in this study. A total of 24 women were recruited through purposive and theoretical sampling. Semi-structured, audio-recorded interviews were undertaken in Chinese and transcribed. Initial coding, focused coding, and theoretical coding approaches were used to identify subcategories and categories, and to construct the emergent theory. The basic social process these women used to deal with the breast cancer diagnosis was identified as: Emerging from the ‘ku’: Fluctuating in adjusting with breast cancer. Four categories were revealed following analysis: confronting challenges, orienting to reality, accommodating the illness, and transforming their lives, which encapsulated the main cognitive and emotional processes in which Chinese women engaged in their adjustment to living with their illness. The core process was influenced by a variety of contextual influences, which were identified as personal factors, social-environmental factors, and some specific cultural factors which emphasized positive changes. Chinese cultural values such as “Wuwei” coping strategies, familial primacy, and Chinese self-disclosure contribute to Chinese women’s adjustment processes and post-traumatic growth experiences. Hence, there is a need to consider Chinese cultural features, in designing culturally tailored supportive programs in multi-cultural clinical settings.

Keywords

adjustment Chinese women breast cancer grounded theory “ku,” post-traumatic growth

Background

Globally, breast cancer is the most common cancer in women (World Health Organization [WHO], 2017). In 2018, over 627,000 women died worldwide as a result of breast cancer, constituting 15% of all cancer deaths among women (WHO, 2017). Besides being the most frequently occurring cancer in Chinese women the age of onset is becoming younger. Breast cancer is the principal cause of cancer death among Chinese women under 45 years (W. Chen et al., 2016). The experience of breast cancer can be devastating to the individual as their physical and psychological well-being is challenged.

The impact of breast cancer may not be exclusively negative. The experience can enable psychological or emotional growth. The term post-traumatic growth (PTG) refers to a positive psychological change experienced as a result of the struggle with highly challenging life circumstances (Tedeschi & Calhoun, 1996). It is evident that some women are indeed able to harness the experience of confronting a breast cancer diagnosis as a turning point and opportunity for positive life changes (Barthakur et al., 2016; Berger & Weiss, 2006; Burke & Sabiston, 2012; Buxton, 2011; Cheng et al., 2016; Garlick, 2009; Ho et al., 2004; Leung, 2007; Oxlad et al., 2008).

In reviewing empirical studies and related theories, different theorists have proposed diverse models or theories of PTG based on Western culture (Joseph & Linley, 2005; Tedeschi & Calhoun, 2004). It is noteworthy that the impact of trauma on a person’s worldviews may also be affected by the cultural context (Kashyap & Hussain, 2017). Culture influences people’s behavior and their understanding and interpretations of the “meaning” of other individuals’ behavior (Spencer-Oatey & Kádár, 2016). Thus, knowing about an individual’s cultural background and values can be helpful in understanding his or her attitudes and behaviors with a traumatic event (Spencer-Oatey & Kádár, 2016).

The applicability of a Western-based PTG model to describe the experience of Chinese women with breast cancer is yet to be determined. Although research on PTG among women with breast cancer is increasing rapidly, most research has been conducted in Western countries. An extensive integrative literature review highlighted there is limited research exploring the PTG experience of women with breast cancer in an Eastern cultural context (Zhai et al., 2019). One study explored the adjustment and coping experiences of Hong Kong Chinese women with breast cancer (Ching et al., 2009, 2012). However, although sharing some similar Chinese cultures, the health care culture and system in Hong Kong differs significantly from that of Mainland China (Tang et al., 2019). Hence, the findings from this Hong Kong study may not apply to women in Mainland China.

In recent years, most studies conducted in Mainland Chinese samples were quantitative and mainly focused on the associations between PTG and post-traumatic stress disorder, coping strategies, and quality of life, using a Western model of PTG. Little has been reported about the PTG process in Chinese women with breast cancer. Two articles were found relating to adjustment and coping among Mainland Chinese women with breast cancer (S.-Q. Chen et al., 2017; Xia et al., 2018). However, S.-Q. Chen et al. (2017) mainly focus on acceptance as a coping strategy for women diagnosed with breast cancer, although some positive change/transcendence experiences pertaining to PTG was articulated. Xia et al. (2018) only emphasize Chinese women’s perspective on meaning in life. Neither study examined how the women transformed themselves step-by-step cognitively and emotionally. In summary, it would seem no study has fully explored PTG theory among Chinese women with breast cancer. Hence, the research purpose was to construct a model (theory) using a grounded theory approach to understand Chinese women’s adjustment process in living with breast cancer.

Method

Methodology

The research question was “what are the processes that Chinese women go through in living with breast cancer.” The specific methodology adopted to answer the research question was the constructivist grounded theory approach advocated by Charmaz (2006). The purpose of the research was to explore Chinese women’s experiences in living with breast cancer and construct a substantive theory or model that could explain Chinese women’s adjustment processes. As such, the aim was to go beyond a simple explanation of participants’ subjective experiences and to reach a theoretical level of interpretation of their adjustment processes in a complex social situation. Constructivist grounded theory methodology, underpinned by symbolic interactionism, focuses on interaction, social processes, and theory development, grounded in data (Charmaz, 2006). From a symbolic interactionist worldview, to fully understand the participants’ experiences, enquirers have to analyze their world with regard to action, meaning, and interaction. Therefore, enquirers are required to interact with all participants, and understand the world from their salient perspectives (Charon, 2007). Grounded theory puts an emphasis on the inquiry process and generating abstract, interpretive understandings and description of the data (Charmaz, 2014), which aligns with symbolic interactionism. Constructivism assumes multiple realities, and allows acceptance of varied realities of each participant, instead of making the assumption that only one reality exists. A constructivist stance allows the researchers and the participants to co-construct the data and theory, thus ensuring that the constructed theory is reflective of participants’ reality and not the researchers’ interpretation (Charmaz, 2014).

Recruitment

Research participants were recruited at a major tertiary hospital in Shanghai, China. Flyers and posters written in Chinese describing the purpose, the criteria for participation, and process of the project along with the primary researcher’s contact details were positioned in relevant outpatient clinics and wards. Women who were interested and willing to participate were able to contact the researcher directly by either phone call, text message, or WeChat message. Women were eligible if they were at least 1 year post diagnosis and had no evidence of metastasis. There were no other inclusion or exclusion criteria.

Participants and Sampling

Initially, 31 women contacted the primary researcher about the study. From these contacts four Chinese women were invited to participate in an interview using purposive sampling. As the study progressed and tentative concepts were developed from the data, we employed theoretical sampling to choose participants with particular personal characteristics relevant to the development of the theory. For example, we found that marital status and religious affiliation had an important influence on participants’ experience in terms of coping styles and PTG manifestations. Therefore, we looked for women with breast cancer who were either single or had different religious affiliations, such as the Buddhist and Christian faiths, to further clarify and refine the development of the theory. We did not seek a pre-determined number of women with any specific characteristic, as the aim was not to establish representation of the population (Charmaz, 2014; Oktay, 2012). Overall, 24 women who met the inclusion criteria participated in the study and no-one withdrew. The women (n = 24) were all Chinese nationals living in Mainland China at the time of the interviews. Table 1 presents a summary of the demographic characteristics of the participants.

Table 1.

Summary of Demographic Characteristics of Participants.

Characteristics	Categories	n
Age (years)	21–30	1
	31–40	2
	41–50	5
	51–60	12
	61–70	4
Number of children	0	4
	1	17
	2	2
	3	1
	>3	0
Marital status	Married/living with a partner	19
	Divorced	1
	Single	3
	Widowed	1
Education	Less than high school	5
	High school graduate	9
	College graduate	6
	Postgraduate	4
Employment	Employed	9
	Not employed	0
	Retired	12
	Homemaker	3
Religious affiliation	Christian	3
	Buddhist	4
	Daoist	0
	Catholic	0
	Non-religion	17
Type of surgery	Lumpectomy	1
	Mastectomy	20
	Bilateral mastectomy	3
Type of treatment	Radiotherapy	0
	Chemotherapy	17
	Radiotherapy and chemotherapy	7
Time since diagnosis	1 year	14
	2–3 years	5
	4–5 years	3
	5–10 years	1
	>10 years	1

Data Collection

Data were collected using semi-structured face-to-face interviews. The initial interview questions were broadly unstructured which allowed for a full and free exploration of participants’ breast cancer journey, for example: “could you please describe your journey since diagnosis?” As data collection advanced, the interview questions became more focused on exploring the themes and categories that were constructed from the previous interview analysis. One example of interview question modification was the development of a question that addressed the issue of “attribution to the cause,” raised during initial analysis. In the first few interviews, some women mentioned they tried to attribute a cause to the breast cancer. To explore this concept further, the following few participants were asked: Have you ever tried to find a reason for the illness? Field notes were taken and an audit trail was maintained throughout the process.

Theoretical sampling guided the interview questions and further data collection until theoretical saturation was achieved, when interviews no longer yielded additional theoretical insights, new codes, themes, or core theoretical categories (Charmaz, 2006). Electronic files of the transcriptions and sub-files for each participant were stored in LabArchives, a cloud-based password protected data storage program based at the University, only accessible to the researchers. Each sub-file was de-identified and labeled with a pseudonym.

Data Transcription and Translation

The face-to-face interviews were conducted in Chinese by Jianxia Zhai whose first language is Mandarin. She also carried out the transcription in Chinese to ensure that the information provided by the participants was not taken out of context and that meaning from the raw data was not lost (Zhou et al., 2011). Chinese was also the language adopted in the coding processes. Simultaneous data collection and data analysis were advocated by Charmaz’s (2006) grounded theory approach. Hence, three rounds of data collection were undertaken for this study. In this study, the first two transcripts from the first round of data collection were translated fully into English and a further four transcripts from the second round of data collection were also translated. Some main quotations from participants that exemplified the interpretive description of the subcategories and categories were also translated. The translation was conducted by a professional, qualified translator who has a medical background and is bilingually competent, which supported accurate faithful and reliable translations of the data. The primary researcher Jianxia Zhai who is bilingually fluent read both the original Chinese transcripts and their English translations to ensure the meaning was not lost in translation, and to minimize language translation issues in the data analysis process.

Data Analysis

The initial, focused and theoretical coding techniques proposed by Charmaz (2006) were used to analyze data. Initial coding was all undertaken on hard copies of transcripts, and then NVivo 11 Pro was used for focused coding. Data analysis was undertaken mainly by the J.Z. and discussed with the other team members in regards to modification of terms or shifts in coding and the naming of subcategories and categories. J.Z. developed initial codes by reading the transcripts and field notes numerous times. Data were then constantly compared with formulate focused codes, which were then further refined (Charmaz, 2006). The codes were collapsed or condensed, and gradually raised to more abstract tentative subcategories and categories using constant comparison methods (Charmaz, 2006). Theoretical coding was utilized to conceptualize possible linkages between the subcategories and categories (Charmaz, 2006). During the process, theoretical memos and diagramming were used to identify and develop links between subcategories and categories emerging from the data. Theoretical memos helped to conceptualize and identify the categories, elucidate their properties, and move forward to construct a substantive theory. For example, some potential theoretical titles were marked using memos, such as “Transforming their lives,” “Emerging from loss: Adjusting in living with breast cancer,” or “Oscillating with suffering: Living and adjusting with breast cancer.” The organization of codes would appear like a family tree if presented diagrammatically. These concepts were further pulled together and raised to an abstract level, and then a theory was constructed by virtue of this iterative process.

Ethical Considerations

Ethical approvals were obtained from the Monash University Human Research Ethics Committee (Project Number: CF15/1598–2015000806) and the Ethics Committee of a major tertiary hospital in Shanghai, China (Project Number: KY2016-228). The explanatory statement was presented and explained to participants, and written consent obtained prior to commencing the interviews. Sensitivity to participants’ emotional health and potential distress the questions might trigger for the women was maintained throughout the interview processes. In addition, the primary researcher is a licensed counselor in China, who thus was able to detect indicators of women’s distress and recommend them to supporting organizations, if necessary. In this study, although several women cried during the self-disclosure process, all of them wished to continue till the end of the interview. To ensure that participants had access to support after the disclosure of their breast cancer experiences, a list of national hot lines and websites for help was provided to them. The confidentiality of participants was addressed throughout the research process. Participants were assigned a unique code in lieu of their given names during interviews and throughout the study.

Rigor

Rigor was addressed using the criteria of credibility, originality, resonance, and usefulness (Charmaz, 2006). Credibility was achieved by a series of techniques such as prolonged engagement, reflexivity, triangulation, and peer debriefing. Regarding originality, the constructed theoretical model may allow for a possible interpretation and understanding of how Chinese women respond to a breast cancer diagnosis. Resonance was facilitated by collecting and analyzing data till theoretical saturation was reached. In terms of usefulness, education, and practice recommendations resulting from the findings have been made with the aim to enhance nursing care in clinical settings and to improve the quality of life of Chinese breast cancer survivors.

Findings

Overview of the Theoretical Model

Following the analysis of the interviews, a core process for this study was identified and described as, “Emerging from the ‘Ku’: Fluctuating in adjusting with breast cancer.” “Emerging” is defined as surviving a difficult situation (Oxford English Dictionary, 2015). “Ku” (苦), a Chinese character, literally means bitterness. It has three meanings in the Xinhua Dictionary (2012): (a) the taste of gall or goldthread (a Chinese herb); (b) suffering from an unpleasant experience, emphasizing the physical hardship; and (c) a very uncomfortable feeling, such as a painful, distressing experience psychologically. The Chinese character “Ku” was used by most Chinese women to describe their inner feelings and experiences when initially encountering breast cancer. Several women used words with a similar meaning to “Ku.” The term “Ku” was chosen as it most relevantly reflects on women’s suffering and loss in this study. The core category describes both the process by which participants adjusted to their condition and the pattern of this process.

A two-part process is presented in this theoretical model. The first part of the core category, emerging from the “Ku,” interprets the central process of how Chinese women encountered challenges following their breast cancer diagnosis, adjusted with the illness, and eventually transformed their lives. The second part of the core category, fluctuating in adjusting with breast cancer, illustrates the pattern of this adjustment process. Most participants living with breast cancer went through a process that entailed a fluctuating pattern. At times women experienced aspects of “Ku,” while on other occasions they strived in coping and adjusting with their illness. However, this was not always accomplished. The women shifted backwards and forwards during their adjustment process in living with breast cancer. This fluctuating pattern of adjustment was associated with the duration of women’s breast cancer diagnosis, becoming less frequent by the time they had experienced some positive changes in comparison to when they were initially diagnosed. Eventually, the participants experienced transformation despite intermittently feeling an underlying sadness throughout the process. The core process assists in interpreting the women’s behaviors, their variations in adjustment pattern alongside the distinctive cultural and social contexts.

The overarching core category frames the central elements of the findings. The four identified categories: confronting challenges, orienting to reality, accommodating the illness, and transforming their lives, encapsulate the main cognitive and emotional processes in which participants engaged in their adjustment to living with their illness. The contextual influences that promoted their adjustment process comprised personal, social-environmental, and cultural factors. These are discussed in more detail in the following sections.

Confronting Challenges

This category incorporated two subcategories: “experiencing loss”, and “questioning personal assumptions and beliefs.” In terms of challenges, the women experienced loss physically and psychologically:

I cannot imagine my own image after removing off the whole breast. How to face my husband, and how to face myself? I felt that I was incomplete as a woman, I was disabled.

I did not cry when I had the surgery. But I cried when my husband accompanied me to the hairdresser’s and I had all my hair shaved off since my hair started to fall off after chemotherapy. You just cannot imagine how sad I felt at that moment when my hair was shaved off. As a woman, it is really depressing that my beautiful hair was gone completely.

In addition, their assumptions about controllability and predictability of their life prior to breast cancer were challenged or even broken at the time of their diagnosis. The women began to question the philosophical values and beliefs they held:

I cried when I knew that I had the cancer. I am not a bad person. Why do I have the cancer?

As a result of loss and questioning personal beliefs and values, the women had some difficulty in retaining continuity of life, which had been challenged or interrupted by the diagnosis of breast cancer. This is encapsulated in the quote below, clearly illustrating the depth of loss and suffering:

I felt like I was hit by a bolt of thunder when I heard the doctor’s words, which fell heavily on my ears, numbing my soul.

Phrases like, “I went blank at the moment” and “I was an incomplete woman,” were all evidence of these women’s challenges. Yet, some women shared that they only felt a transient sadness or shock for a very short time. One woman shared she accepted her illness within a few hours, rebounding quickly from the breast cancer diagnosis and downplaying the significance of her illness. These women positioned the diagnosis within the context of other experiences in life:

When I heard the diagnosis (breast cancer) from the doctor, I felt a shock and then came to accept it shortly. It is not a big deal to me; I experienced a lot before the illness.

Faced with the challenges brought about by their breast cancer, the women experienced “Ku” in contrasting degrees. The women then sought to find an explanation for their illness.

Orienting to Reality

The second category was composed of “searching for an explanation,” “seeking coping strategies,” and “accepting the illness”. When encountering breast cancer, initially, the majority of women asked: “Why me” and then endeavored to search for an explanation of the illness. On identifying a reason for their illness, which could be physical, psychological, spiritual, or religious, participants generally adopted various coping strategies to adjust with breast cancer. Besides certain common coping strategies, such as venting or diverting attention, some utilized culture-specific coping strategies such as “let go attitude” and “Wuwei” coping (a non-action coping). As one woman explained:

It is a truth that I got breast cancer. I never think too much, but just let it be. It is useless to worry about as well.

The woman adapted to her illness by just letting nature take its course. Similarly, others just emptied their minds and let go of everything. Participants learned to make sense of their illness, fitting the breast cancer into their current life schema by using various coping strategies. They gradually came to terms with the illness and accepted the reality:

When bad things like breast cancer happen in your life, there is no option but to accept everything. I accepted the truth as time went on.

In contrast, some women rebounded swiftly from the diagnosis and quickly felt able to explain the reason for the breast cancer, accepting their illness as part of life. However, the women varied in relation to the time that they took to adjust and come to terms with their illness. The majority of women indicated that it took them a while to come to terms with the illness, while they were challenged with the question, “Why me?” In contrast, some women shared that they did not dwell on the breast cancer diagnosis for any extensive period of time, instead, only a couple of hours or a few days. These women did not express any apparent downturn in emotion and had articulated that they just felt transient sadness or shock following their diagnosis. These women shared that they were able to bounce back quickly when encountering breast cancer. Yet, the women still shared experiences of positive changes in terms of their health awareness and behavior, enhanced altruism and new life orientation.

Accommodating the Illness

This category comprised of “finding meaning for sustaining life” and “reflecting on life.” When coming to terms with their illness, the women usually found motivation for sustaining their lives. Significant others (e.g., husbands, parents, or children) had critical meaning for the women who were experiencing breast cancer. These people in their lives served as a motivation for the women to survive during their time of loss. Taking responsibility and minimizing the burden for significant others were found to be important forces that enabled most women to accommodate their illness and helped them in adjusting:

My son is still young. He has not got married and settled down to a job. On the other hand, I need to be responsible for my mum and dad, because my siblings never take care of my parents. I am the elder sister, and nobody would look after them if I died. It was this kind of thinking that supported me to get through the hardship.

Most women found a sustaining force and moved forward to fulfill their role-related responsibilities. They gradually made deliberate reflections on the management of their illness and their future life:

I want to live, that is it, so I cooperated with the doctor actively, and even it (breast cancer experience) was bitter. I have to live, and I really get through now.

As the participants managed to come to terms with their illness, they found a meaning for sustaining their lives, and for reappraising themselves at various stages of illness. They gradually integrated the breast cancer experience into their lives, and then were able to begin transforming their lives. As a result, it appeared they experienced some positive changes and even transcendence in terms of interacting with self, others, and an ultimate power.

Transforming Their Lives

The final category is composed of “renewing self-perception,” “encountering changes in relationships,” and “altering philosophical values and beliefs.” The following quotation highlights this phenomenon:

I feel like I am a changed person. In general, the changes are positive, and they are real changes.

Most women revealed that they felt improved, closer relationships with their family and friends. They became more aware of and sensitive to others’ need, and even had an enhanced compassion for others as well. However, some women also encountered an indifference of relationships:

I feel that after becoming ill, I cherish what I need to treasure more and spend more time with my families and children.

I was engaged before the illness, but my boyfriend gradually isolated me and distanced me. I could feel that everything was different since then, so finally, we broke up.

However, this positive transformation appeared incomplete. Some memories or triggers, such as a routine physical check-up, constantly reminded them of what they had gone through. It also brought the women back to the reality that they were still living with a diagnosis of breast cancer. Underlying sadness was a common and universal phenomenon to participants:

Sometimes, I feel a sadness in my inner heart when I see my scar or other triggers. It is not predictable, and the unhappy feelings just pop up in my mind. But most of the time I am okay.

For participants, the underlying sadness occurred throughout the entire adjustment process. Hence, their cognitive and emotional processes fluctuated as they sought to find meaning for sustaining their lives, reflecting on how to move on over and over again to emerge from the “Ku.” Participants’ adjustment process was significantly impacted by the contextual influences with which they interacted or by their inherent characteristics.

Contextual Influences

Data revealed a variety of contextual influences affecting the women’s entire adjustment process ranging from personal factors (past experiences and some personality characteristics) to broad social factors (hospital-based interpersonal interactions, family support, and community-based support). In particular, the uniqueness of cultural-specific features such as Chinese self-disclosure was identified as contributing to participants’ adjustment process. It seemed that most women were likely to internalize their emotions and feelings, and tended not to show their “Ku” in front of others:

I am not willing to tell other people that I am sick and many people including my colleagues and friends do not know of my illness (diagnosed more than 2 years). I put my sadness and unhappiness in my inner heart and never showed it in front of my family as well. If I showed them, the family was unhappier than I was.

I am not willing to share the illness experience, my emotions with family . . . I do not want to increase the burden to my family, in particular my husband. If I shared my distress to them, they would feel sad as well. My husband took good care of me every day since my illness, and it was not easy to look after a patient you know, physically and psychologically. I should not burden him psychologically anymore.

Most participants were unwilling to discuss their illness with others. They all worried about either losing face or burdening their families if they revealed their illness.

Discussions

Consistent with PTG theories developed in Western countries (Calhoun et al., 2010; Joseph et al., 2012; Joseph & Linley, 2005; Tedeschi & Calhoun, 2004), our resulting theory also highlights that cognitive processes and coping strategies are central in the process of PTG. However, two nuanced differences and distinctions in terms of patterns of adjustment and self-disclosure are particularly worthy of noting.

Our theory posits that Chinese women’s pattern of adjustment in living with breast cancer is a fluctuating pattern, rather than a fixed linear pattern, which was implicitly stated in the major PTG theories developed in Western countries (Calhoun et al., 2010; Joseph et al., 2012; Joseph & Linley, 2005; Tedeschi & Calhoun, 2004). This fluctuating pattern is a fundamental principle of Chinese women’s adjustment process. Given that culture shapes an individual’s worldview and framework to respond to a traumatic event, adjustment process patterns need to be understood in a specific cultural context (Calhoun et al., 2010). In light of the literature (Calhoun et al., 2010; W. Chen et al., 2016; Dong et al., 2015; Ramos et al., 2018), it is evident that the frequency and pattern of disclosure (willingness vs. unwillingness) demonstrates some cross-cultural differences in PTG theories. Despite this, the women in this study also experienced PTG. In this study, these cultural-specific factors were found to have significant influences on the women’s process of finding an explanation to their illness, interpretation of body image, and finding a meaning for sustaining their lives as well as seeking coping strategies. In addition to a cultural explanation for this varied adjustment pattern, the nature of trauma may partly account for differences in adjustment. Cancer has some distinguishing characteristics, such as continuing uncertainty regarding potential recurrence, as compared with other traumatic events (such as a major traffic accident, interpersonal violence). Hence, it may affect the PTG process in certain ways (Kolokotroni et al., 2014). The fluctuating adjustment process in this study is likely to be consistent with the model of coping with bereavement, described as a dynamic, oscillating process (Stroebe & Schut, 2010). The women in this study experienced loss physically or psychologically in varied degrees, and hence they were likely to demonstrate some features of coping with grief when adjusting with their breast cancer diagnosis. While grief reaction to a cancer diagnosis is well documented (Glaser et al., 2019; Gökler-Danışman et al., 2017; Vergo et al., 2017), it has not been identified as a part of PTG.

Post-traumatic growth theories or frameworks developed in the Western individualistic cultural context tend to be, “positive-oriented, encourage talking, foster being proactive to one’s social network, be more optimistic, and perhaps discourage people from taking avoidance coping strategy” (Matsui & Taku, 2016, p. 150). In comparison, given the distinctive interdependent, collective, and other-oriented cultural features (Hu et al., 2018), the majority of women in this study tended to minimize their personal desires and emotional and psychological needs. The women were likely to handle their negative emotions and thoughts internally to meet social expectations. Specifically, the women were not willing to directly express their emotions to others, not even their families. “Face-saving” is regarded as an important value which influences most Chinese people’s behavior (G. M. Chen, 2014). Public expression of negative emotions is discouraged, and is regarded as losing face as well (G. M. Chen, 2014; Kinnison, 2017). In addition, it is also a potential disruption to harmonious interpersonal relationships to express negative emotional problems with non-family members or friends. Thus, the individual may hide their negative emotions and not share with others in an honest way in public, to save face and maintain the harmony of interpersonal relationships (Kinnison, 2017; Yan, 2016). In addition, minimizing family burden may also restrict women from expressing their illness-related feelings and seeking help from their family. Consequently, the women tend to put their needs and concerns behind them, and put on a brave face to please their family and to meet the social expectations of their culture.

This contrast with Western PTG theories or frameworks which highlight that willingness to self-disclose is a contributing factor to PTG experiences (Calhoun et al., 2010; Tedeschi & Calhoun, 2004). Therefore, these findings suggest that willingness to self-disclose may not be a necessary factor for PTG. Hence, PTG without disclosure, we suggest, needs to be considered as a possible contributing factor in enabling transformation and growth.

Holistically, our constructed PTG theoretical model also added some insights of other primary PTG theories, identified by Joseph and Linley (2005). First, they argued that previous PTG theories were not comprehensive enough to be able to explain variance in responding to traumatic events. This newly constructed theory addresses and explains variations in the women’s adjustment processes, particularly in relation to the time that they took to adjust to the illness. Second, the predominant and most comprehensive functional-descriptive model of PTG offered by Tedeschi and Calhoun (2004) has been criticized for not being able to account for why individuals might be motivated toward PTG (Joseph & Linley, 2005; Kashyap & Hussain, 2017). Emerging from the “Ku” theory addresses this limitation through explaining how and why the women transformed their lives step-by-step, that is, most women were motivated to grow to fulfill their role-related obligations, particularly in relation to the Chinese value of familial primacy. This value promoted the women’s meaning making process and would seem to enable the occurrence of PTG. Hence, our theory offers some new insights into understanding the adjustment process and PTG experience among women with breast cancer from a Chinese cultural background.

The suggestions and recommendations of this study are provided specifically for nursing practice and education in China. In addition, looking at a broader cultural context, these findings might offer some insights for multi-cultural health care providers. The study findings may facilitate psychosocial care by informing health care professionals, in particular registered nurses, to raise their awareness and understanding so that they can better support women as they journey through the experience of adjusting to live with breast cancer. The following sections provide several recommendations in light of the research findings to inform nursing practice and education.

The implications for clinical practice within China are centered on the need for the creation of the role of breast care nurses to support women during their breast cancer journey. Such a role is known to enhance continuity of care for this group of women. Within Western countries our theory provides insights for health care professionals caring for women from a Chinese cultural background. Practitioners need to be mindful and reflective of how this group of women deal with breast cancer, which may be different from women raised in a Western culture. Hence, there should be a focus on understanding the nuances of Chinese cultural influences when designing multi-cultural education programs for health care professionals in multi-cultural work forces. Indeed, culturally tailored breast cancer support programs need to be designed when providing care to people from different ethnic groups (Xu et al., 2017).

Conclusion

The findings of this study demonstrate the complex and dynamic journeys of Chinese women living with breast cancer. Our theory of emerging from the “Ku” offers an alternative perspective to Western theories of PTG, presenting instead a non-linear process influenced by culturally specific factors. Our findings have implications for development of breast cancer services within China, and can assist health care professionals caring for women with a Chinese cultural background in other countries.

Study Limitations

Grounded theory can help better understand and illuminate the adjustment process among Chinese women with breast cancer. Grounded theory focuses on developing a substantive theory that explains people’s behaviors in certain contexts, through the use of theoretical sampling. This poses limitations in generalizing the findings to other contexts and settings. A total of 66% of women in this study were 51 years or older, who could have more life experiences than younger women. Given age at diagnosis might be associated with experience of positive growth, therefore, future research should expand to explore and understand the influence of age on PTG experience. Furthermore, most women in this study underwent mastectomy rather than lumpectomy. Thus, the findings may not be applicable to women who underwent lumpectomy surgical treatment, which may put another possible limitation to the study. However, some elements of the findings, such as how Chinese women with breast cancer grow from adversity and the coping strategies they use to deal with illness, may well be applicable to other Chinese women who do not live in China though still hold onto their cultural values.

Footnotes

Acknowledgements

We express our heartfelt gratitude to the participants. We acknowledge the support of Professor Hong Jiang and Ms Ting Ye for assistance in facilitating the access and recruitment of participants. The first author acknowledges Monash Graduate Education for offering her the scholarship to undertake this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jianxia Zhai

Author Biographies

Jianxia Zhai Nursing and Midwifery, Monash University, Melbourne Victoria Australia.

Jennifer M. Weller-Newton is an associate professor at Department of Nursing, The University of Melbourne, Melbourne; Adjunct Associate Professor, Nursing and Midwifery, Monash University, Melbourne Victoria Australia; Associate Clinical Professor, School of Nursing, McMaster University, Hamilton, Ontario Canada.

Kaori Shimoinaba is a lecturer at Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia.

Hong Chen is a nurse unit manager, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.

Beverley Copnell is an associate professor at School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia.

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