Volume 6, Issue 4 (November 2019)                   Avicenna J Neuro Psycho Physiology 2019, 6(4): 159-164 | Back to browse issues page

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Jalali M, Rahimi M. The Relationship between Psychological Hardiness and Social Support in Women with Breast Cancer. Avicenna J Neuro Psycho Physiology 2019; 6 (4) :159-164
URL: http://ajnpp.umsha.ac.ir/article-1-159-en.html
1- Department of Psychology, Faculty of Educational Sciences & Psychology, Islamic Azad University, Buin Zahra Branch, Karaj, Iran.
2- Department of Psychology, Faculty of Educational Sciences & Psychology, University of Kharazmi, Tehran, Iran.
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Considering the reports published by the World Health Organization, the universal load of cancer has duplexed throughout the last 30 years [1]. Breast cancer is one of the current diseases worldwide caused by the rare and incontrollable duplication of cells due to different factors, such as genetic, glandular, and environmental factors [2]. Breast cancer ranks third in terms of the burden of disease and is the major cause of death by more than 400000 deaths (ranking fifth) among Iranian women [3, 4]. Exposure to cancer can directly affect a person’s several aspects of life [5]. The diagnosis of breast cancer and its therapeutic process is an extremely distressing and troublesome experience for patients [6, 7]. Women with breast cancer, especially in developing countries, are at greater risk for physical and mental health problems; the detection of cancer may be associated with more emotional and physical disorders [8]. 

It has been demonstrated that patients with breast cancer are exposed to psychiatric symptoms and psychosocial issues, which may cause mental and social disorders affecting their lives [9-11]. Personality characteristics of women with breast cancer, like psychological hardiness, determine the side effects of stressful life events [11-13]. Psychological hardiness consists of three basic interrelated hypothetical components. Hardy people are easily committed to their lives, believe that they have some control over the causes and solutions of life obstacles, and view changes in life and adaptive requests as challenges and chances for development rather than menaces [14]. 

Hardiness traits among females with breast cancer are a buffer in perceived stress [15]. People with a high level of hardiness are possibly more capable of enduring the negative results of life stressors. Their resistance to illness likely results from perceiving life changes as less stressful events or from having more capacity to cope with life changes [13]. Hardiness has a positive relationship with mental welfare [16] associated with using the problem-oriented comparative strategies [17] and attention to positive events of life [12]. Moreover, Aflakseir et al. highlighted the significant role of psychological hardiness and perceived social support in the personal growth of breast cancer survivors [13]. 

Social support is another key concept, which is related to mental health and is conceptualized as individuals’ cognitive assessment of the quantity of support provided to them by the environment and others. Social support is very impressive in an understanding of symptoms severity, as well as the quality of life of the patient because the individual’s quality of confronting the stress is extremely affected by the methods of receiving social support [9, 18]. Social support theorists believe that social support focuses on individuals’ cognitive evaluations of their immediate environment and the level of certainty about the approachability of help and support [18]. Although there are significant individual differences between patients’ opposition to the disease symptoms and adjustment to its outcomes, psychological distress at the primary stages is accompanied by levels of pain and fatigue, performance status, disease impact on life, life events, and perceived protection. Therefore, seeking social support is one of the important methods for confronting psycho-social stressful factors [9].

Several studies showed a positive and significant relationship between the level of family support and adaptation to cancer [8, 9, 19]. Moreover, social support has been reported as one of the determinants of cancer control in women with breast cancer in Iran [20]. Furthermore, supportive actions are effective in ameliorating the general health status and quality of life of patients with cancer [8].

Behavioral factors act as a part of the development of cancer, but psychiatric intricacies may appear in patients with cancer due to various psychological effects that have neurophysiologic and conceptual traits. Such psychiatric complexities and psychological challenges destroy adaptation abilities, and decrease the quality of life of the patient, and also negatively affect the flow of disease and response to treatment [10]. Hence, as noted above, the aim of this study was to survey the relationship between psychological hardiness and social support in women with breast cancer.

The internal factors, including commitment (vs. alienation), control (vs. powerlessness), and challenge (vs. need for security) help individuals not only remain strong under stressful conditions but also perform better under stressful situations [21, 22]. Studies have shown that individuals with high levels of hardiness are more likely to employ effective coping strategies to deal with problems, compared with those with low levels of hardiness.

Materials and Methods

This correlational research was conducted on 110 married women with breast cancer who referred to a hematology/oncology ward of Shafa Hospital, Ahvaz in 2018-2019. The sample size was determined using the Morgan table. This table can be used when there is no access to community variance. The purpose of the study was explained to all patients and they presented an agreement before their participation in the study. Moreover, they were assured of data confidentiality and all the questionnaires were kept nameless. The research ceremonial follows the ethical guidelines of the declaration of Helsinki (1975). The research at the beginning selected the qualified individuals based on the inclusion criteria, including being diagnosed with breast cancer, the age of over 18 years, the ability to read and write, being informed of their cancer diagnosis, and no other medical illnesses. Exclusion criteria included being exhausted during completing questionnaires and feeling of weakness. 

The demographic and disease characteristics questionnaire consisted of three items, such as age, duration of illness, and occupational status, as well as the Kobasa Psychological Hardiness Questionnaire [3] and the Multidimensional Scale of Perceived Social Support (MSPSS) were the tools used in this study (Table 1).

The Kobasa Psychological Hardiness Questionnaire 

Kobasa in 1988 used this questionnaire to measure psychological hardiness [21]. This questionnaire consists of 50 items and the answers are rated on a 3-point Likert scale ranging from 0 (completely false) to 3 (completely true). Items 6 to 21 and 28 to 50 are scored reversely. The questionnaire includes three subscales of commitment, control, and challenge. Higher scores indicate more hardiness and vise versa. Its internal validity was obtained 53.317 using Bartlett’s Chi-Square test, which was a desirable validity [11]. In Iran, Ghorbanifar evaluated the reliability of this questionnaire and demonstrated that the correlation coefficient of control, commitment, and challenge was 0.70, 0.52, and 0.52, respectively [11]. Also, its reliability was approved with the Cronbach alpha coefficient of 0.88 in this study. 

The Multidimensional Scale of Perceived Social Support (MSPSS) 

The MSPSS was used to measure the level of family support. The scale was developed by Zimet et al. in 1988 to assess social support perceived by the family, friends, and important persons in life [22]. This scale consisted of 12 items and three subscales, including family (items 3, 4, 8, and 11), friends (items 6, 7, 9, and 12) and others (items 1, 2, 5, and 10). The scale is scored on a 5-point Likert scale from entirely agree to entirely disagree. Bruwer et al. using Cronbach’s alpha achieved the internal consistency of 86 to 90% for the subscales the MSPSS and 86% for the whole scale [23]. In Iran, the obtained Cronbach’s alpha for the social support received by the family, friends, and others was 89%, 86% and 82%, respectively [24]. Also, in this study, its reliability was approved using the Cronbach alpha coefficient of 78%, 66%, and 62% for three dimensions of social support received by the family, friends, and others, respectively. Data were analyzed using SPSS V. 23 software and descriptive and inferential statistics (one-sample t-test and Pearson correlation coefficient). P≤0.05 was considered as significant. 


The Mean±SD of age of the patients with breast cancer was 46.80±4.08), ranging from 28-58 years. Furthermore, the average number of unemployed women was more than employed women with breast cancer.

According to Table 2, psychological hardiness among women with breast cancer with a Mean±SD of 3.2±0.50 was moderate level, the commitment, control, and challenging components were at weak, good, and relatively good levels, respectively.

Table 3 presents the descriptive statistics (Mean±SD and one-sample t-test) to indicate social support status.

The t value of greater than 1.96 indicates that the variable is in good condition, the t value of between 1.96 and -1.96 represents the moderate condition, and the t value of less than -1.96 indicates its poor condition. According to Table 3, it can be said that social support among women with breast cancer in terms of perceived support from friends and family was in good condition, whereas had a poor level in terms of support by others.

Hypothesis 1: There is a significant relationship between psychological hardiness and social support among women with breast cancer.

According to Table 4, the relationship between psychological hardiness and social support of women with breast cancer was significant (P=0.05). Therefore, hypothesis one was confirmed. Meaning that the higher the level of perceived social support, the higher the psychological hardiness of women with breast cancer.

Hypothesis 2: There is a significant relationship between psychological hardiness components and social support among women with breast cancer.

According to the results of Table 5, the relationship between social support and psychological hardiness components among women with breast cancer was significant at the level of 0.001;

therefore, there was a positive significant relationship between social support and the components of commitment, control, and challenging of psychological hardiness in women with breast cancer. Thus, hypothesis two was confirmed.


The result of this study showed a significant relationship between psychological hardiness and perceived social support, which prevents psychological distress to deal with stress among women with breast cancer. It means that the higher the level of perceived social support, the higher the psychological hardiness of women with breast cancer, which was consistent with several other studies [10-15], and no study was found inconsistent with this finding.

Abdollahi et al. showed the significance of hardiness in decreasing perceived stress impacts on hope and reported its clinical implications for health practitioners [15]. Patients with high hardiness are more able to cope with the negative outcomes of life (illness, bad events, accidents, etc.). These individuals’ hardiness likely results from the perception of life changes as less stressful or having a higher capacity to cope with life changes. Several studies have indicated that psychological hardiness and social support are significant psychosocial factors for illness recovery [13-18]. 

Hardiness provides flexibility and protects public health. Therefore, people who have hardiness are physically and mentally healthy [4]. Hardy individuals reported less anxiety in response to the stressors of life [16]. There was a significant but inverse correlation between psychological hardiness and mental health score. Psychological hardiness as an internal resistance resource reduces the detrimental effects of stress and prevents the improvement of physical and psychological disorders [14]. Kakpour and Teymouri found that hardy women are more likely to attend treatment sessions than others [25, 26]. The people with high psychological hardiness compared with those who have lower psychological hardiness are less likely to be physically or mentally damaged in response to life pressures. Psychological hardiness increases the tolerance level of individuals with breast cancer [27]. 

Social support is a fundamental factor regarding the care for cancer patients. It creates a social interaction starting with communication making an empathic relationship and eventually leads to a welfare circle for the patient. Increasing self-reliance and capability or competency to carry out essential tasks is considered as modifiers of social support. Possibly, the interpersonal relationship helps people to cope with the condition and causes a good sense [8]. In a study, 10 questionnaires collected from 208 studies demonstrated a positive and significant relationship between the level of family support and the type of disease control. Among the components of social support, family support has been able to anticipate the variance of psychological health at a remarkable level that should be considered in the course of the amelioration and treatment of breast cancer. Social support has a significant effect on the development, treatment, and improvement of breast cancer [28].

One of the limitations of this study was studying a random sample of women with cancer of the Shafa Hospital in Ahvaz that limits the generalizability of the results to all patients with breast cancer. Another limitation was using of self-reported questionnaires for data collection. The small sample size of the included studies was another potential limitation of this study.


The findings showed that psychological hardiness and social support are two important health factors in women with breast cancer. Also, considering the relationship between psychological hardiness and perceived social support, it is suggested to establish interventional programs and counseling programs for the family members of the patients to provide more support and promote psychological hardiness of the patients to reduce their psychological distress.

Ethical Considerations

Compliance with ethical guidelines

All ethical principles were considered in this article. The participants were informed about the purpose of the research and its implementation stages; they were also assured about the confidentiality of their information. Moreover, they were allowed to leave the study whenever they wish, and if desired, the results of the research would be available to them. 


This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions

All authors contributed in designing, running, and writing all parts of the research.

Conflict of interest

The authors declared no conflict of interest.



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Article Type: Research Article | Subject: Clinical Psychology
Received: 2019/04/15 | Accepted: 2019/09/6 | Published: 2019/11/1

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