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Endah Sari Purbaningsih, Muadi, Iin Indra Nuraeni. (2022). Analysis
of Psychological Status and Sleep Quality in Breast Cancer Patients.
Journal of Eduvest . Vol 2(9): Page 1785-1792
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Eduvest – Journal of Universal Studies
Volume 2 Number 9, September, 2022
p- ISSN 2775-3735 - e-ISSN 2775-3727
ANALYSIS OF PSYCHOLOGICAL STATUS AND SLEEP
QUALITY IN BREAST CANCER PATIENTS
Endah Sari Purbaningsih
1
, Muadi
2
, Iin Indra Nuraeni
3
ABSTRACT
One of the health problems that many women experience is
breast cancer. This diagnosis becomes a stressor that will
greatly affect the patient's physical, psychological, spiritual
and social condition. Another problem experienced by breast
cancer patients is sleep disorders that can affect sleep quality.
The purpose of this study was to determine the relationship
between psychological status and sleep quality in breast
cancer patients. The type or research design used is
descriptive correlation with a cross sectional approach. The
number of samples is 30 respondents, data collection using
the standard DASS questionnaire for psychological status and
PSQI for sleep quality, previously the patient was given
informed consent. Data analysis using Spearman rank. The
research was conducted at Waled Hospital, Cirebon. The
results showed that there was a relationship between
psychological status and sleep quality in breast cancer
patients with p value = 0.004 < = 0.05. The correlation
coefficient value of 0.509 means that the strength of the
correlation is moderate and positive, meaning that the better
the psychological status of the respondent, the higher the
correlation. good sleep quality too. The conclusion of this
study is that psychological status is positively correlated with
sleep quality, the better the psychological status, the better
the sleep quality of breast cancer patients.
KEYWORDS
Sleep Quality, Psychological Status
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Endah Sari Purbaningsih, Muadi, Iin Indra Nuraeni
Analysis of Psychological Status and Sleep Quality in Breast Cancer Patients
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INTRODUCTION
The problem faced by the world today is about human health with the
epidemiological transition (shifting of health problems from infectious diseases to
non-communicable diseases, resulting in an excessive burden for all countries in
the world. On the one hand, the state has not succeeded in controlling the problem
of infectious diseases which shows trend towards an increase in cases (Afuiakani,
Djohgo, & Bina, 2017).
One of the health problems experienced by many women is reproductive
problems, including breast cancer. Breast cancer is a type of malignant tumor that
attacks breast tissue. The characteristics of breast cancer that are often
experienced include pain, there is a lump that is getting bigger, the skin around the
breast becomes wrinkled like an orange peel, sometimes accompanied by fluid or
blood from the nipple (Henry & Crawford, 2005). Women who are diagnosed
with cancer are usually already at an advanced stage so that many treatments are
not adequate or appropriate (Alifiyanti, Hermayanti, & Setyorini, 2017).
Cancer is a condition of cells that experience loss of control from their
normal mechanisms, experiencing abnormal and massive growth. (Low and
middle income countries), cancer is the cause of death, reaching 70%. Data
sourced from Dharmais Cancer Hospital in 2018 showed that the most cancer
cases were breast cancer (19.18%) and was the largest contributor to all types of
cancer ( Kemenkes RI, 2019). The World Health Organization (WHO) based on
the results of the Global Cancer Observatory in 2018 stated that the highest
incidence in Indonesia was breast cancer, which was 58.256% or 16.7% of the
total 348,809 cancer cases (Organization, 2019).
The Ministry of Health (Kemenkes) stated that the prevalence of breast
cancer in Indonesia reached 42.1 people per 100,000 population, with an average
death rate from cancer of up to 17 people per 100,000 population. Based on the
2018 Basic Health Research (Riskesdas) data, the prevalence of cancer in
Indonesia showed an increase from 1.4 per 1000 population in 2013 to 1.79 per
1000 population, the highest prevalence was in the DI Yogyakarta province,
which was 4.86 per 1000 population, after that are West Sumatra 2.4779 per 1000
population and Gorontalo 2.44 per 1000 population (Ministry of Health RI, 2019).
Based on the findings from the World Health Organization's International Agency
for Research on Cancer (IARC) cancer is the cause of death, this has experienced
a shift in trend, previously cardiovascular diseases such as stroke, heart disease
were the cause of death, but this has decreased due to better treatment (Bailey Jr,
McWilliam, Buysse, & Wesley, 1998).
Breast cancer is a very frightening diagnosis for all women. Because this
diagnosis becomes a stressor that will greatly affect the patient's physical,
psychological, spiritual and social conditions. One of the psychological reactions
of the patient is fear, anxiety, stress, despair and even depression, and not
infrequently in the middle of undergoing therapy the patient commits suicide.
Research from (SUKMA, 2018) that most respondents with breast cancer
experience mild to moderate depression. Similar to what (De Sousa, Sonavane, &
Mehta, 2012) said, not a few cancer patients experience psychological impacts,
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and each person is different depending on the stage and severity, type of treatment
(Handayani & Udani, 2017). The psychological impacts that are often felt include
helplessness, anxiety, shame, decreased self-esteem, stress, anger. 30% of patients
experience adjustment problems, and depression (20%).
Another impact of breast cancer is physical changes, one of which is sleep
disturbances, which can affect the patient's psychological condition. Sleep
disturbance is a condition where the quality, quantity of sleep in a person is
disturbed. Quality sleep is very much needed by cancer patients who are
undergoing therapy at the hospital to regenerate and repair to optimize the body's
cells (Potter & Perry, 2005). NREM sleep stimulates the production of growth
hormone (Growth Hormone) which will help repair body tissues. REM sleep is
needed to maintain brain tissue and is important for cognitive recovery (Assefa,
Diaz-Abad, Wickwire, & Scharf, 2015).
Sleep disturbances in cancer patients can also occur due to the effects of
chemotherapy, as revealed by (Fink, 2016) respondents who received
chemotherapy >6 cycles had poor sleep quality. In several other studies, it was
stated that chemotherapy also had the effect of worsening functional status,
namely the inability to carry out its role including fulfilling the need for rest and
sleep
Preliminary studies conducted on 8 breast cancer patients, 4 of whom said
that there was a deep sadness that was very influential in being able to sleep well,
easily awakened and occasionally there was a feeling of anger that made it
difficult to go back to sleep. The other 2% said that if there was no pain, the
patient could sleep even though it was still easy to wake up occasionally. And the
other 2 just said sometimes it's hard to sleep. This condition is clarified in the
results of research by (Alifiyanti et al., 2017) respondents (31) with cancer
patients with mastectomy had poor sleep quality such as sleep latency, sleep
duration, efficiency of sleep habits, and daytime dysfunction. (SETIYARINI &
Effendy, 2018) in their research said that almost 26% of cancer patients
experienced severe depression,
Patients who experience deep sadness, to stress and depression often occur
related to their condition, both during hospitalization and during treatment at
home. Psychological conditions that are not good can lead to biological conditions
that are not good as well. To restore a good biological condition, good quality
sleep is needed. Based on this, researchers are interested in conducting further
research related to the relationship between psychological status and sleep quality
in breast cancer patients in the Hematology and Oncology Room of the Waled
Regional General Hospital, Cirebon Regency.
RESEARCH METHOD
The type of research used is descriptive correlation with a cross sectional
approach. The population and sample were breast cancer patients who were
hospitalized at Waled Hospital. The sampling technique used accidental sampling
as many as 30 respondents. The instrument used to measure psychological status
using the Depression anxiety and stress scale (DASS) questionnaire version 21
consisting of 3 sets of self-report scales to measure emotional state (depression,
Endah Sari Purbaningsih, Muadi, Iin Indra Nuraeni
Analysis of Psychological Status and Sleep Quality in Breast Cancer Patients
1788
anxiety and stress), this questionnaire was adopted from Lovibond & Lovibond .
This questionnaire consists of 21 statements. The value of the validity test is 0.34
– 0.71 and the reliability test based on Cornbach's alpha is 0.93. Each statement is
given a score of 0 to 3. 0 if it has never been experienced; 1 if sometimes
experienced; 2 if experienced frequently; experienced very often. The
measurement results on this variable use 4 categories, namely: Good = 1-5, Mild
= 6-7, Medium = 8-14, Bad = 15-21, The instrument used to measure sleep quality
is the Pittsburgh Sleep Quality Index (PSQI) questionnaire.) developed by
Contreas et. Al (2014). The PSQI questionnaire was published by the University
of Pitssburgh with a cronbach alpha value of 0.83. This questionnaire consists of
open questions (no. 1 to 4), and closed questions (no. 5 – 8) with a score range of
0 – 3. 0 if in the last one month there has been none; 1 if experienced 1 time in 1
week; 2 if experienced 2 times in 1 week; and 3 if experiencing >3 times a week.
Interpretation of sleep quality Sleep quality is good if the score is 5, sleep quality
is poor if the score is >5 Analysis of the data used is by using the calculation of
the Spearman Rank test. Before the research is carried out, the research ethics first
goes to the Mahardika School of Health Ethics Commission ( STIKes)
RESULTS AND DISCUSSION
Table 1 Frequency Distribution of Psychological Status in Breast Cancer
Patients
Independent Variable
frequen
cy
Percentage
Psychological Status :
1. Normal
2. Light
27
3
90.0
10.0
TOTAL
30
100
Source: Primary Data (2022)
Based on the table above, it can be explained that of the 30 respondents the most
respondents who had normal psychological status, namely 27 respondents (90.0%).
Table 2 Frequency Distribution of Quality in Breast Cancer Patients
Dependent Variable
frequency
Percentage
Sleep Quality
1. good
2. Bad
21
9
70.0
30.0
TOTAL
30
100
Source: Primary Data (2022)
Based on table 2 above, it can be explained that of the 30 respondents, most of
them have good sleep quality, namely as many as 21 respondents (70.0%)
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Table 3 Relationship between Psychological Status and Quality in Breast
Cancer Patients
Psychological
Status
Sleep Quality
TOTAL
good
Bad
n
%
n
%
n
%
Normal
1
77.8
6
22.2
27
90.0
Ligh
0
0
3
100
3
10.0
TOTAL
21
70.0
30.0
30
100
Source: Primary Data (2022)
Based on table 5.3 above, it can be explained that most of the respondents who
experienced normal psychological status had good sleep quality (77.8%), and all
respondents who had mild psychological status disorders all had poor sleep quality
(100%). Further statistical tests using the Spearman Rank tests are obtained as follows:
Table 4 Spearman Rank Test Results Relationship Psychological Status
With Quality In Cancer Patients
Correlation
Coefficient
Direction
Correlation
Category
-value
Relationship between
Psychological Status and
Quality in Breast Cancer
Patients
0.509
Positive
Moderate
0.004
Source: Primary Data (2022)
The results of the statistical test of bivariate analysis that have been carried out
using the Spearman rank test get p value = 0.004 < = 0.05, then H0 = rejected which
means that there is a relationship between Psychological Status and Quality in Breast
Cancer Patients at Waled Hospital, Cirebon Regency, on the coefficient value The
correlation value is 0.509, meaning that the strength of the correlation is at moderate
strength and positive means that the better (normal) the psychological status of the
respondent, the better the quality of sleep (ρ value: 0.004, : 0.05, r: 0.509).
A. Psychological status in breast cancer patients
Psychological is a picture of a personality and abilities possessed by everyone in
general and these abilities are related to the ability to be prepared for stress which is
caused by several factors so that directly or indirectly affect a person in perceiving and
behaving. This psychological status also applies to everyone without exception. The
description of the psychological status of patients with chronic diseases plays a very
important role in the treatment process and the healing phase.
The results of this study indicate that of the 30 respondents the most are
respondents who have normal psychological status, namely 27 respondents (90.0%).
Psychological status includes depression, anxiety and stress conditions experienced by
breast cancer patients in particular and generally experienced by everyone in any
condition. The results of this study are in line with the research of Afuikani , et.al (2018),
at the beginning of being diagnosed with cancer, almost all of the participants
experienced the stages of denial, anger and anger until eventually they could accept it ,
because these participants admitted that if they continued to be sad, it might cause them
Endah Sari Purbaningsih, Muadi, Iin Indra Nuraeni
Analysis of Psychological Status and Sleep Quality in Breast Cancer Patients
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to suffer more quickly. death for always denying reality, shutting himself in until finally
not undergoing proper treatment.
The results of this study explain that a person's response in dealing with grieving
or loss conditions is different, many factors influence it. Definitively stress can occur over
events that are being experienced by the patient, anxiety is a feeling of fear experienced
by the patient or someone about something that has not been experienced or has occurred,
it can be said that anxiety is a reaction or body alarm in preparation for dealing with
stress. Stress and anxiety have a characteristic that is very similar between the two, the
difference is that stress occurs due to stressful conditions, while anxiety is due to a form
of worrying about an event that has not previously occurred. As a consequence of
psychological status such as anxiety, depression and stress disorders .
B. Sleep quality in breast cancer patients
The results showed that of the 30 respondents, most of them had good sleep
quality, as many as 21 respondents (70.0 %). Sleep is a condition that is carried out
repeatedly and there is a change in the status of consciousness within a certain time
(Perry, Potter, & Ostendorf, 2013). Sleep activity is characterized by the absence or
minimal activity, a process of physiological changes in the body occurs, and is
accompanied by a decrease in response to external stimuli. Sleep occurs because of the
release of serotonin in the raphe in the pons and midbrain, called the Bulbar
Synchronizing region (BSR). When a person tries to sleep with his eyes closed, in a
relaxed state the stimulus to the SAR will decrease, the BSR takes over the task until
sleep finally occurs (Perry, Potter, & Ostendorf, 2013).
Sleep quality is one of the important symptoms of sleep disorders and other
accompanying diseases, sleep quality is important as one of improving health and the
recovery process (Perry, Potter, & Ostendorf, 2013). Another opinion explains that sleep
quality is a multi-complex situation because it involves several dimensions, also includes
qualitative and quantitative aspects such as length of sleep, time needed to fall asleep,
frequency of awakening from sleep, depth and depth of sleep.
C. Relationship between psychological status and sleep quality in breast cancer
patients
Cancer is a disease caused by faulty cell division until finally there is an
abnormal growth of new cells, massive, difficult to control until they metastasize.
Chronic disease conditions such as breast cancer experienced by patients will greatly
affect their psychological status. Conditions of stress, depression for ordinary people
mean a condition of sad, moody feelings or emotions, unhappiness, lack of enthusiasm to
live life (Perry, Potter, & Ostendorf, 2013).
The psychological status of a person who is diagnosed with a chronic disease for
the first time will have various experiences in responding to the diagnosis as bad news.
And will respond like denial, anxiety, isolate yourself until you can finally accept it, as
expressed in the theory of grieving by Kublerr Ross, which consists of 5 phases/stages
when a person loses and is grieving, including denial, anger, bargaining, depression and
acceptance . Sleep quality is one of the important symptoms of sleep disorders and other
accompanying diseases, sleep quality is important as one of improving health and the
recovery process (Perry et al., 2013). Another opinion explains that sleep quality is a
multi-complex situation because it involves several dimensions, also includes qualitative
and quantitative aspects such as length of sleep, time needed to fall asleep, frequency of
awakening from sleep, depth and depth of sleep (Melastuti & Avianti, 2015).
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Several factors that affect sleep quality include psychological status such as
anxiety, stress, depression. Often the condition of a person who is anxious or stressed and
depressed even experiences disturbances in his sleep. Psychological conditions that are
not good have an effect on increasing levels of norepinephrine in the blood by stimulating
the sympathetic nervous system (SSS). This increase in norepinephrine levels affects
during sleep in stage IV NREM and also REM sleep until the resulting condition is that a
person will be easier to wake up frequently. Psychological status (anxiety, depression,
stress) in cancer patients in particular will stimulate the production of catecholamines
(norepinephrine and dopamine), histamine, acetylcholine, glutamate which causes a
person to be awake (Romito, Cormio, Giotta, Colucci, & Mattioli, 2012).
An important role that regulates sleep and wakefulness is the neurotransmitters
histamine (affects wakefulness) and GABA which affects sleep. When a person
experiences insomnia, a lot of histamine is produced in the body while not much GABA
is produced, on the Contrary, during the day a lot of GABA is produced and not much
histamine is produced as a result, the patient experiences excessive sleepiness
(SETIYARINI & Effendy, 2018).
The results showed that most of the respondents who experienced normal
psychological status had good sleep quality (77.8%), and all respondents who had
mild psychological status disorders all had poor sleep quality (100%). The results
of the statistical test of bivariate analysis that have been carried out using the
Spearman rank test get p value = 0.004 < = 0.05, then H0 = rejected which means
that there is a relationship between Psychological Status and Quality in Breast
Cancer Patients at Waled Hospital, Cirebon Regency, on the coefficient value The
correlation value is 0.509, which means that the correlation strength is at moderate
strength and positive means that the better (normal) the psychological status of the
respondent, the better the quality of sleep (ρ value : 0.004, : 0.05, r: 0.509).
The results of this study explain that a person's response to accepting his
condition is very varied. As the results of research conducted by Purwati (2014)
on 40 breast cancer patients with Severe anxiety has poor sleep quality as much as
70%. Conditions of anxiety, stress, depression often interfere with sleep so that
the quality of sleep becomes poor. While the quality of sleep is very important for
a person's health status, especially in people with illness, because sleep functions
as a maintenance of health, especially the heart during the NREM stage 4 process,
the release of growth hormone to repair brain cells, muscles relax progressively,
the body's energy storage as a result of a decrease in the rate of basal metabolic
rate (Perry et al., 2013).
If the quality of sleep is poor, it will cause several impacts, namely
physical effects such as excessive sleepiness, sad and tired facial expressions,
fatigue, increased blood pressure, dizziness, stiff neck. And other impacts are
psychological impacts such as apathy, decreased response, lazy to talk, reduced
memory, confusion, hallucinations arise. In this study, the value of the correlation
coefficient obtained a value of 0.509, meaning that the strength of the correlation
was at moderate strength and positive, meaning that the better (normal) the
psychological status of the respondent, the better the quality of sleep . On the
other hand, if the psychological status is not in a good condition, the tendency for
sleep quality is to be in a bad condition.
CONCLUSION
Endah Sari Purbaningsih, Muadi, Iin Indra Nuraeni
Analysis of Psychological Status and Sleep Quality in Breast Cancer Patients
1792
Psychological status is related to the quality of breast cancer patients,
conditions of anxiety, stress, depression often interfere with sleep so that the
quality of sleep becomes poor. While the quality of sleep is very important for a
person's health status, especially in patients with disease, because sleep serves as a
maintenance of health, especially the heart. Recovery in breast cancer patients
(chemotherapy) really requires good physical health. Good psychological status
will contribute to physical health status. Good physical health will have an impact
on good sleep quality. The results of the analysis showed that there was a
relationship between psychological status and sleep quality in breast cancer
patients with p value = 0.004 < = 0.05. The correlation coefficient value of 0.509
means the strength of the correlation is moderate and positive, meaning that the
better the psychological status of the respondent, the higher the correlation. good
sleep quality too.
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