The major purpose of this work was to develop an Arabic version of the Mini-MAC instrument useful among Moroccan population. To this end, a sample of 203 breast cancer women was investigated using exploratory and confirmatory factor analysis. After dispatching five items, the current version was validated yielding the five-factors structure of the original version of Mini-MAC instrument (Helpless/Hopeless, Anxious Preoccupation, Fighting Spirit, Avoidance, and Fatalism). The same structure, proposed originally by Watson et al, has been already validated by many authors working on different types of cancer (15–19, 21). Our validated version showed similar psychometric properties as the original version (15), and other Mini-MAC validated version (17, 19, 22–24).
The only difference between previous findings and ours resides in the degree of factors reliability and the factor intercorrelations. In this study, the coefficients reliability for AP, FS, CA and FA are significantly high compared to some previous studies (15, 17, 18, 24), but seem nearly similar to certain others (19, 25).
The factors belonging to the group of passive coping strategies or maladjustment (HH/AP) are positively correlated with each other, but negatively correlated to those belonging to the group of active coping strategies or adjustment (FS, CA, and FA), and vice versa. This contradicted the original study (15), but corroborated that of Patoo et al’s study (19) who reported the same trend of correlation between these factors. CA showed a significant positive correlation with FS as well as with FA. Only the second association was pointed out in the original study (15), while the same results was reported by other studies (17, 18, 21, 24). In line with Watson et al’s work (15), our findings also showed a mild negative correlations between CA and AP; and a high negative correlation between CA and HH. The latter correlation was reported only by Patoo, Allahyari (19) who showed a mild negative correlation between the two factors. Indeed, these results, and in contrast to most previous studies, suggest that CA is an indicator of positive adjustment, and is positively associated with FS and FA. Nevertheless, many authors consider CA as an active distraction strategy that may facilitate problem-focused coping (19, 21, 26).
Some studies have grouped Mini-MAC factor adjustment to cancer into two types of strategies: passive coping strategies (Fatalism, Anxious Preoccupation and Helpless/Hopeless), and active strategies (Fighting Spirit and Cognitive Avoidance) (16, 38). However, this is not the case for the current study, where fatalism, and Cognitive Avoidance were found as positive coping styles (19, 21), and not a maladjustment as it is stated by some authors (18, 22). Besides, Chinese study has divided Mini-MAC subscales into two groups called Negative and Positive Emotions. The first one, an indicator of maladjustment, includes Anxious Preoccupation and Hopelessness, whereas the second, indicator of positive adjustment, includes Fatalism and Fighting Spirit. The positive emotion group was found significantly associated with Cognitive Avoidance (21).
Fatalism showed a negative correlation with the factors of the passive coping strategies, and a positive correlation with those of the active strategies. These findings corroborated some studies (18, 19, 24, 26), and at the same time contradicted others (16, 17, 22).
In contrast to western countries, Fatalism is considered as a positive coping strategy in Moroccan culture, the same results have been found in a Persian, Korean and Chinese countries (19, 21, 24). Of particular note, Moslem people found their faith on destiny and fatalism, which has a different connotation from western countries; fatalism means acceptance and satisfaction based on the person’s reasons first, and then trust in God. That means positive attitude gathering fatalism with fighting spirit. These findings are consistent with those of Islamic (19) and Asiatic versions (21, 24, 26) while they contrast with most western countries (16–18, 22). They have asserted that Fatalism represents a positive adaptation and psychological battle with cancer. Our findings confirm the previous argument that FA is an adaptive coping tendency having no correlation with distress (24, 25).
These interpretations should consider some caveats concerning methodological issues. In this light, most previous studies of Mini-MAC validation are based on exploratory factor analysis, which makes them less reliable (15, 17, 19, 21–25). Whereas few studies are grounded on confirmatory factor analysis (16, 17, 26). Additionally, the factor structure reported by different unstandardized studies should be variant due to many variables such as the type of cancer, sample size, culture, age, gender, patients, and phases of cancer. To deduce well grounded conclusions about the reliability and validity of the Mini-MAC instrument for its future application, both analyses were adopted in the current study. The fivefactor measurement model showed an excellent fit according to the cut-off values of Absolute, incremental and parsimonious fit indices. The validity and reliability aspects were considered based on CFA outputs, and the fitness indices were supported by strong literature being referred (30).
However, this study has some limitations that should be highlighted. The sampling was conducted in a single regional hospital, and targeted a small sample size of cancer patients with specific type of cancer. In addition, the sample is small, and contains patients with different age range; cancer stages of disease, receiving different medical care at one Hospital. Hence, these findings cannot, however, be extrapolated to all Moroccan cancer patients from different regions. Thus, more inclusive studies should be performed, while taking into account these variables. Moreover, longitudinal survey are needed to assess the predictive validity of the scale for psychosocial outcomes.
This shorten version of 24 items is a quick, valid, and reliable instrument in assessing cancer-specific coping of the adjustment response to cancer. It will allow physicians to know how negative and positive psychological adjustment to the illness could affect clinical practice. Hence, the acceptable psychometric properties obtained in this Arabic Mini-MAC guarantees its future use in clinical practice to measure various coping responses of breast cancer women.