Psychological flexibility and coping behaviors in cervical cancer patients: Moderating role of illness perception

Abstract

BACKGROUND

Cervical cancer poses significant physical and psychological challenges, often leading to maladaptive coping behaviors that affect treatment adherence and quality of life. While psychological flexibility is known to promote adaptive coping, its relationship with coping behaviors in cervical cancer patients remains underexplored, and the potential moderating role of illness perception in this association has not been established.

AIM

To explore the relationship between psychological flexibility and cancer coping behaviors in patients with cervical cancer, and to analyze the moderating role of illness perception in this relationship.

METHODS

A convenience sampling method was used to select 216 patients with cervical cancer for inclusion in this study. The Multidimensional Psychological Flexibility Inventory-24, Cancer Behavior Scale-3.0, and Brief Illness Perception Questionnaire were used for data collection. SPSS 26.0 software was applied for descriptive statistics, Pearson correlation analysis, and hierarchical regression analysis were also performed.

RESULTS

The total psychological flexibility score in patients with cervical cancer was 65.32 ± 10.25. The score of the positive coping dimension in cancer coping behaviors was 38.67 ± 7.54, and the score of the negative coping dimension was 25.43 ± 6.89. The total illness perception score was 42.15 ± 8.36. Pearson correlation analysis showed that psychological flexibility was significantly positively correlated with positive coping behaviors (r = 0.452, P < 0.05), and significantly negatively correlated with negative coping behaviors (r = -0.387, P < 0.05). Illness perception was significantly positively correlated with negative coping behaviors (r = 0.324, P < 0.05), and significantly negatively correlated with psychological flexibility (r = -0.298, P < 0.05). Hierarchical regression analysis showed that after controlling for demographic variables, psychological flexibility significantly positively predicted positive coping behaviors (β = 0.396, P < 0.05) and significantly negatively predicted negative coping behaviors (β = -0.342, P < 0.05). Illness perception played a significant moderating role in the relationship between psychological flexibility and negative coping behaviors (β = 0.187, P < 0.05), but had no significant moderating effect on the relationship between psychological flexibility and positive coping behaviors (β = 0.093, P > 0.05).

CONCLUSION

Higher levels of psychological flexibility in patients with cervical cancer are associated with a greater tendency to adopt positive coping behaviors. Illness perception enhances the effect of psychological flexibility on negative coping behaviors.

Key Words: Cervical cancer; Psychological flexibility; Cancer coping behavior; Illness perception; Moderating effect

Core Tip: This study examines the relationship between psychological flexibility and coping behaviors in cervical cancer patients, with illness perception as a moderator. Results show that higher psychological flexibility is associated with more positive coping and less negative coping. Illness perception significantly moderates the link between psychological flexibility and negative coping, suggesting that interventions targeting both factors may help reduce maladaptive coping responses in this population.

INTRODUCTION

Cervical cancer is one of the most common malignant tumors of the female reproductive system, with high morbidity and mortality worldwide, seriously threatening women’s life and health[1,2]. With the continuous progress in early screening and comprehensive treatment technologies, the survival time and prognosis of cervical cancer patients have been significantly improved[3,4]. However, the physical pain caused by the disease itself, adverse reactions during treatment, uncertainty of prognosis, and changes in social roles often lead to obvious psychological stress responses such as anxiety, depression and distress, which further affect patients’ psychological adaptation and coping styles[5-7].

Coping behaviors are important cognitive and behavioral strategies for individuals to deal with disease-related stressors, which are directly related to treatment compliance, rehabilitation effect, quality of life and long-term prognosis of cancer patients[8-10]. Positive coping behaviors can help patients actively face disease challenges, relieve negative emotions and improve disease adaptation ability, while negative coping behaviors such as avoidance, denial and resignation will aggravate psychological distress, reduce treatment participation and hinder physical and mental recovery[11-13]. Therefore, exploring the influencing factors and internal mechanisms of cancer coping behaviors in cervical cancer patients is of great significance for formulating targeted psychological intervention strategies and improving clinical outcomes.

Psychological flexibility refers to the ability of individuals to fully accept current internal experiences, maintain cognitive openness, and take adaptive actions consistent with personal values when facing pressure and pain[14]. As a core protective factor of mental health, psychological flexibility has been confirmed to play an important role in psychological adaptation of cancer patients. Previous studies have shown that higher psychological flexibility is conducive to reducing cancer-related fatigue, negative emotions and perceived stress, and promoting patients to adopt positive coping strategies[15,16]. However, most relevant studies focus on general cancer populations, and there is still a lack of targeted research on the direct relationship between psychological flexibility and cancer coping behaviors in cervical cancer patients[7].

Illness perception is a comprehensive cognitive, emotional and belief evaluation of individuals on their own disease, which dominates how patients interpret disease information, regulate emotions and choose coping styles[17]. A large number of studies have confirmed that negative illness perception is significantly associated with increased negative emotions, poor self-management behavior and low quality of life in cervical cancer patients[15,18-20]. Patients with negative illness perception tend to regard the disease as serious, uncontrollable and threatening, thus being more inclined to adopt negative coping styles. In contrast, positive and objective illness perception can help patients reduce fear, actively seek medical support and adopt adaptive coping methods[6].

According to the stress-coping model and illness perception theory[21-23], illness perception may act as a moderating variable to regulate the strength or direction of the relationship between psychological flexibility and coping behaviors. That is, the influence of psychological flexibility on coping behaviors may differ under different levels of illness perception. However, existing research rarely integrates the three variables into a unified framework, and it is still unclear whether illness perception plays a moderating role in the relationship between psychological flexibility and positive/negative coping behaviors among cervical cancer patients[23].

Therefore, this study included cervical cancer patients and aimed to explore the correlation between psychological flexibility and cancer coping behaviors, and further verify the moderating effect of illness perception. The results are expected to enrich the theoretical research on psychological adaptation of cervical cancer patients, and provide a theoretical basis and practical reference for clinical nursing to develop targeted psychological interventions, optimize patients’ coping styles and promote physical and mental health[15,24].

MATERIALS AND METHODS

Patients

Using a convenience sampling method, 216 patients with cervical cancer treated in our hospital from June 2025 to January 2026 were selected as participants. Inclusion criteria were as follows: (1) Confirmed diagnosis of cervical cancer by postoperative pathological examination, in accordance with International Federation of Gynecology and Obstetrics (FIGO) stage I-IV criteria; (2) Age ≥ 18 years; (3) Clear consciousness, normal verbal communication ability, and ability to understand and complete the questionnaire independently; (4) Undergoing active treatment or regular follow-up; and (5) Voluntary participation and signed informed consent. Exclusion criteria were as follows: (1) Presence of other malignant tumors; (2) Severe heart, liver, kidney, or other organ dysfunction; (3) History of mental illness, cognitive impairment, or severe neurological disorders; (4) Unable to cooperate with questionnaire investigation due to critical condition or unstable vital signs; and (5) Incomplete clinical data. The study was reviewed and approved by the Medical Ethics Committee of Nanjing Women and Children’s Healthcare Hospital (decision No. PJ-2025KY017-001). Informed consent was obtained from all participants. All procedures were performed in accordance with the Declaration of Helsinki.

Research tools

Brief Illness Perception Questionnaire: The Brief Illness Perception Questionnaire is a self-rating scale consisting of nine items. The dimensions are divided as follows: Five items assess cognitive representations of illness, two items assess emotional representations, one item evaluates patients’ understanding of their own disease, and one open-ended item assesses perceived causes, asking patients to list the three most important causes of the disease. Except for the etiological assessment item, the remaining eight items are scored on a 0-10 scale. The grading criteria are as follows: < 2 indicates mild, 2-4 mild to moderate, 4-6 moderate, 6-8 moderate to severe, and > 8 severe. Higher total scores indicate more pronounced negative cognition and emotional experience related to the disease[17]. The Chinese version of the questionnaire has been applied in patients with various diseases and has demonstrated good reliability and validity. Cronbach’s α coefficient was 0.85, and the test-retest reliability was 0.83. Construct validity analysis showed that the single-factor model fitted well (χ²/df = 2.41, goodness-of-fit index = 0.91, adjusted goodness-of-fit index = 0.88, root mean square error of approximation = 0.08), indicating that the scale can effectively evaluate illness perception in Chinese patients[25].

Multidimensional Psychological Flexibility Inventory-24: The Multidimensional Psychological Flexibility Inventory was developed by Rolffs et al[14]. The Chinese version of the Multidimensional Psychological Flexibility Inventory-24 has been revised and verified for reliability and validity, and is suitable for measuring psychological flexibility in the Chinese population[26]. The scale includes six dimensions: Acceptance, cognitive dissociation, focus on the present, self-as-context, clarity of values, and commitment to action, with four items in each dimension, for a total of 24 items. A 6-point rating scale is employed, ranging from 1 (never like this) to 6 (always like this). By summing up the scores of all 24 items, a total score is obtained, with a range from 12 to 72. A higher score indicates a greater level of psychological flexibility in individuals.

Cancer Behavior Scale-3.0: The Cancer Behavior Scale-3.0 was used to assess disease-related coping behaviors in cancer patients. It includes four dimensions: Active coping, passive resignation, emotional catharsis, and information seeking, with a total of 28 items[8]. A 4-point scale is used (1 = never, 4 = always), with higher scores indicating more prominent use of the corresponding behavior. In patients with cervical cancer, the Cronbach’s α coefficient of the Chinese version ranged from 0.75 to 0.83, and the test-retest reliability ranged from 0.70 to 0.77. Confirmatory factor analysis showed good model fit (χ²/df = 2.54, Comparative Fit Index = 0.92)[11].

Data collection

A total of 230 questionnaires was distributed to eligible patients by trained investigators. Before the investigation, the purpose, process, and confidentiality of the study were explained in detail. Questionnaires were completed anonymously and face-to-face in the inpatient wards and outpatient departments after routine medical care. Investigators checked each questionnaire on the spot to ensure completeness and logical consistency. Finally, 216 valid questionnaires were collected, with an effective response rate of 93.91%.

Statistical analysis

SPSS 26.0 software was used for data processing and analysis. Measurement data were expressed as mean ± SD. Pearson correlation analysis was conducted to examine the relationships between psychological flexibility, illness perception, and each dimension of cancer coping behavior. Hierarchical regression analysis was used to test the moderating effect of illness perception. Demographic variables (age, education level, marital status, and disease duration) were entered in the first step as control variables, psychological flexibility was entered in the second step as the independent variable, illness perception was entered in the third step as the moderating variable, and the interaction term between psychological flexibility and illness perception was entered in the fourth step. A value of P < 0.05 was considered statistically significant.

RESULTS

General information on study subjects

A total of 216 patients with cervical cancer were enrolled in this study. Disease duration was defined as the time interval from the first pathological diagnosis of cervical cancer to the date of questionnaire completion. The general demographic and clinical characteristics are presented in Table 1.

Table 1 General and clinical characteristics of the participants (n = 216).

Characteristics	Categories	n (%)
Age (years, mean ± SD)	53.64 ± 8.25 (35-72)	-
Education level	Primary school or below	68 (31.48)
	Junior high school	82 (37.96)
	High school or above	66 (30.56)
Marital status	Married	185 (85.65)
	Unmarried/divorced/widowed	31 (14.35)
Disease duration (years, mean ± SD)	2.35 ± 1.02 (1-5)	-
FIGO stage	I-II	132 (61.11)
	III-IV	84 (38.89)
Histopathological type	Squamous cell carcinoma	187 (86.57)
	Adenocarcinoma	23 (10.65)
	Other rare types	6 (2.78)
Treatment status	Undergoing active treatment	124 (57.41)
	Post-treatment follow-up	92 (42.59)
Treatment modality	Surgery alone	41 (18.98)
	Surgery + chemotherapy/radiotherapy	119 (55.09)
	Chemoradiotherapy alone	49 (22.69)
	Palliative care	7 (3.24)
Monthly family income (RMB)	< 3000	52 (24.07)
	3000-5000	94 (43.52)
	> 5000	70 (32.41)
Medical insurance	Basic medical insurance	197 (91.2)
	Commercial insurance/self-funded	19 (8.8)

FIGO: International Federation of Gynecology and Obstetrics.

The mean age of the patients was 53.64 ± 8.25 years, ranging from 35 years to 72 years. The mean disease duration was 2.35 ± 1.02 years, ranging from 1 years to 5 years. In terms of education level, 68 cases (31.48%) had primary school or below education, 82 cases (37.96%) had junior high school education, and 66 cases (30.56%) had high school or above education. For marital status, 185 cases (85.65%) were married, and 31 cases (14.35%) were unmarried, divorced, or widowed. According to FIGO stage, 132 cases (61.11%) were stage I-II, and 84 cases (38.89%) were stage III-IV.

Regarding histopathological type, 187 cases (86.57%) had squamous cell carcinoma, 23 cases (10.65%) had adenocarcinoma, and 6 cases (2.78%) had other rare types. In terms of treatment status, 124 cases (57.41%) were undergoing active treatment, and 92 cases (42.59%) were in post-treatment follow-up. Treatment modalities included surgery alone in 41 cases (18.98%), surgery combined with chemotherapy or radiotherapy in 119 cases (55.09%), chemoradiotherapy alone in 49 cases (22.69%), and palliative care in 7 cases (3.24%).

In terms of economic status, 52 cases (24.07%) had a monthly family income < 3000 RMB, 94 cases (43.52%) had 3000-5000 RMB, and 70 cases (32.41%) had > 5000 RMB. Regarding medical insurance, 197 cases (91.20%) had basic medical insurance, and 19 cases (8.80%) had commercial insurance or were self-funded.

Descriptive statistics of study variables

The descriptive statistics of psychological flexibility, cancer coping behaviors, and illness perception are shown in Table 2. The total score of psychological flexibility was 65.32 ± 10.25. For cancer coping behaviors, the score of positive coping was 38.67 ± 7.54, and the score of negative coping was 25.43 ± 6.89. The total score of illness perception was 42.15 ± 8.36.

Table 2 Scores of psychological flexibility, cancer coping behaviors and illness perception, mean ± SD.

Variables	Number of entries	Total score range	Actual score	Dimension mean score
Psychological flexibility	24	24-44	65.32 ± 10.25	2.72 ± 0.43
Cancer coping behaviors	28	28-112	64.10 ± 14.43	2.29 ± 0.52
Positive coping	16	16-64	38.67 ± 7.54	2.42 ± 0.47
Negative coping	12	12-48	25.43 ± 6.89	2.12 ± 0.57
Illness perception	8	0-80	42.15 ± 8.36	3.51 ± 0.69

Correlation analysis of the variables studied

Pearson correlation analysis was conducted to examine the relationships between psychological flexibility, illness perception, positive coping and negative coping (Table 3). Psychological flexibility was significantly positively correlated with positive coping (r = 0.452, P < 0.01), and significantly negatively correlated with negative coping (r = -0.387 P < 0.01). Illness perception was significantly positively correlated with negative coping (r = 0.324, P < 0.01), and significantly negatively correlated with psychological flexibility (r = -0.298, P < 0.01). No significant correlation was found between illness perception and positive coping (r = -0.087, P > 0.05).

Table 3 Pearson correlation analysis of key variables (n = 216).

Variables	Psychological flexibility	Positive coping	Negative coping	Illness perception
Psychological flexibility	1	0.452a	-0.387a	-0.298a
Positive coping	0.452a	1	-0.123	-0.087
Negative coping	-0.387a	-0.123	1	0.324a
Illness perception	-0.298a	-0.087	0.324a	1

^aP < 0.01.

Associations of demographic and clinical variables with outcome variables

Age, education level, treatment status, treatment modality, and monthly family income were significantly associated with psychological flexibility, positive coping or negative coping (all P < 0.05). These variables were included as control covariates in the subsequent hierarchical regression analysis to control for confounding effects.

Moderating effect of illness perception

Hierarchical regression analysis was performed to test the moderating role of illness perception (Table 4).

Table 4 Results of hierarchical regression analysis of the moderating effect.

Dependent variables	Step of regression	Predictor variables	β	SE	t	R²	ΔR squared	ΔF
Positive coping	1	Demographic variables	-	-	1.56	0.028	0.028	1.56
	2	Psychological flexibility	0.396	0.062	6.39b	0.202	0.174	42.35b
	3	Illness perception	-0.075	0.065	-1.15	0.207	0.005	1.23
	4	Psychological flexibility × illness perception	0.093	0.063	1.48	0.216	0.009	2.15
Negative coping	1	Demographic variables	-	-	1.32	0.024	0.024	1.32
	2	Psychological flexibility	-0.342	0.058	5.89b	0.156	0.132	35.67b
	3	Illness perception	0.285	0.061	4.67b	0.234	0.078	18.45b
	4	Psychological flexibility × illness perception	0.187	0.072	2.60a	0.261	0.027	6.78a

^aP < 0.05.

^bP < 0.01.

For positive coping as the dependent variable: After controlling for demographic and clinical covariates, psychological flexibility significantly positively predicted positive coping (β = 0.396, P < 0.01). The interaction term of psychological flexibility and illness perception was not significant (β = 0.093, P > 0.05), indicating that illness perception had no significant moderating effect on the relationship between psychological flexibility and positive coping.

For negative coping as the dependent variable: After controlling for covariates, psychological flexibility significantly negatively predicted negative coping (β = -0.342, P < 0.01), and illness perception significantly positively predicted negative coping (β = 0.285, P < 0.01). The interaction term was significant (β = 0.187, P < 0.05), suggesting that illness perception played a significant moderating role in the relationship between psychological flexibility and negative coping.

DISCUSSION

The present study revealed that the overall level of psychological flexibility among cervical cancer patients was relatively low, suggesting considerable potential for improvement. This finding may be attributed to the malignant nature of cervical cancer, as the disease trajectory and treatment-related burdens often induce substantial psychological stress, which may restrict patients’ capacity to flexibly regulate cognition and behavior and impede adaptive responses to disease-related distress[5]. With regard to coping behaviors, most patients tended to adopt positive strategies when facing disease challenges, although a subset still exhibited negative coping patterns. Regarding illness perception, participants generally displayed moderate negative cognitive and emotional evaluations, viewing cervical cancer as a threatening health condition and expressing concerns about prognosis and quality of life[17,27].

Consistent with prior evidence, psychological flexibility was significantly associated with cancer coping behaviors. Patients with higher psychological flexibility were more likely to accept aversive internal experiences, disengage from unhelpful cognitive fusion, mobilize internal and external resources, and engage in positive coping behaviors such as active problem-solving and support-seeking[18,27]. Conversely, lower psychological flexibility was linked to greater emotional entanglement and a higher propensity for negative coping including avoidance and denial[19]. These correlational results imply that psychological flexibility may serve as a modifiable psychological resource supporting adaptive coping in this population, although causal inferences cannot be drawn from cross-sectional data.

Notably, illness perception exerted a differential moderating role in the links between psychological flexibility and coping styles, with significant moderation observed only for negative coping. Mechanistically, negative illness perception may amplify the association between low psychological flexibility and negative coping. Among patients with limited psychological flexibility, strong negative illness beliefs may intensify feelings of fear and helplessness, thereby reinforcing maladaptive coping repertoires[17,28]. In contrast, patients with higher psychological flexibility may better regulate cognitive and behavioral responses even in the presence of moderately negative illness perceptions, weakening the tendency toward negative coping. The non-significant moderation effect on positive coping may reflect that positive coping relies more on intrinsic motivational and regulatory resources, rendering it less sensitive to the modulating influence of illness perception. These differential patterns should be interpreted with caution given the cross-sectional design[19,29].

From a clinical perspective, these findings may provide preliminary implications for supportive care. Interventions targeting psychological flexibility, such as acceptance and commitment therapy or mindfulness-based programs, could potentially encourage more adaptive coping responses[17,30]. In addition, personalized health education and cognitive restructuring may help patients develop more balanced illness perceptions[25,28]. For patients with low psychological flexibility, combined interventions addressing both psychological flexibility and illness perception might be particularly helpful in reducing negative coping. However, these suggestions remain hypothetical; clinical implementation requires validation through well-designed controlled trials before routine application[31,32].

Several limitations of this study should be acknowledged. First, convenience sampling was used, which may limit the representativeness of the sample and generalizability of the findings. Second, the cross-sectional design only permits correlational analyses and cannot establish causal pathways or temporal relationships among psychological flexibility, illness perception, and coping behaviors. Third, the study did not account for potential confounding factors including social support, family functioning, and caregiver burden, which may influence the observed associations. Future research may employ probability sampling to enhance representativeness, adopt longitudinal designs to clarify causal mechanisms, and conduct randomized controlled intervention trials to evaluate the efficacy of strategies targeting psychological flexibility and illness perception. Additional studies exploring multifactorial models will help strengthen the evidence base for clinical practice.

CONCLUSION

In cervical cancer patients, higher psychological flexibility is associated with more frequent positive coping behaviors and less frequent negative coping behaviors. Illness perception moderates the relationship between psychological flexibility and negative coping, but not positive coping. These cross-sectional results suggest that interventions aimed at improving psychological flexibility and optimizing illness perception may help promote adaptive coping and psychological well-being. Caution is warranted in translating these findings into clinical practice, and further longitudinal and interventional research is needed to confirm causal relationships and establish the effectiveness of targeted supportive interventions.