2.1. Study design and participants
We recruited 269 adolescent malignant-bone tumor patients treated from January 2023 to December 2023 at two tertiary care hospitals in Zhejiang Province, China. Inclusion criteria: (1) patients diagnosed with malignant bone tumors by pathological tissue examination, who knew of their condition, and met 2020 World Health Organization (WHO) bone tumor classification rules [12]; (2) patients aged 10–19-years-old [1] (by following per under the age standard of adolescents stipulated by WHO; (3) patients with a degree of writing ability and verbal communication; and (4) patients aware of their condition and who voluntarily participated in the study.
Exclusion criteria: (1) patients with other cancers or more severe underlying diseases; (2) Patients with psychiatric diseases or cognitive disorders; (3) patients with a history of anxiety and depression; and (4) patients with severe hearing and speech disorders.
According to statistical requirements, the sample size had to be 5–10 times the number of variables. The total number of statistically analyzed variables in this study was 18 items (10 in the General Information Questionnaire; two in the Fear of Progression Questionnaire-Short Form (FoP-Q-SF); three in the Simple Coping Style Questionnaire (SCSQ); and three in the Family Hardiness Index (FHI). In our study, 5–10 times the number of dependent variables was used, thus, the sample size had to be at least 90–180 cases, which we expanded by 20% to finally include 269 patients, accounting for missing or invalid questionnaires.
This study was approved by the Institutional Research Ethics Committee (Approval No. I2023053).
2.2. Procedures
The questionnaire consisted of four sections: demographic characteristics, FoP-Q-SF, FHI, and SCSQ. The investigators received consent from the hospital ethics committee before the investigation, contacted the head of the bone tumor department, the head nurse, and the charge nurse in advance, and obtained their full understanding and cooperation. Investigators explained the purpose and significance of the survey to patients and their families before radiotherapy or surgery and other treatments on the day of admission, and distributed questionnaires after informed consent was obtained. Investigators instructed patients and family members on a “one-on-one” basis to complete questionnaires and objectively answer questions. Investigators distributed 280 questionnaires to adolescents with malignant bone tumors and excluded 11 ineligible questionnaires. Therefore, 269 valid questionnaires were recovered with a valid return rate of 96.1%.
2.3. Measures
2.3.1. Sociodemographic characteristics
Questionnaires included 10 items: age, sex, place of residence, education, type of health insurance, religion, per capita monthly household income, tumor stage, and number of chemotherapy treatments.
2.3.2. FoP-Q-SF
This questionnaire was compiled by Mehnert [13], translated by Wu [14] in 2015, and is mainly used to measure and examine a patient’s fear of disease progression. The scale consists of two dimensions: physical health and social family. It contains 12 entries, using a 5-point Likert scale, with a total score of 12–60 points: one point for “never” and two points for “rarely,” two points for “sometimes” and one point for “never”, two points for “rarely” and two points for “sometimes”. The higher the score, the more serious a patient’s fear of disease progression is; i.e., a score ≥ 34. Such scoring establishes if a patient is experiencing psychological dysfunction. Cronbach’s α coefficient for the scale was 0.886, with α coefficients for physical health and social and family dimensions being 0.829 and 0.812, respectively [14].
2.3.3. FHI
This index was proposed by Mccubbin et al. [15] and revised in 2014 by Liu et al. [16]]. It consists of three dimensions: responsibility, control, and challenge, with 20 entries. Entries 4–9, 11, 13, and 18 consider responsibility dimensions, entries 1–3, 10, 19, and 20 consider control dimensions, and entries 12, 14, and 17 consider challenge dimensions. A Likert 4-point scale is used, with “strongly disagree” scoring 1, “disagree” scoring 2, “agree” scoring 3, “strongly agree” scoring 4,. The scale includes “strongly disagree” (1 point), “disagree” (2 points), “agree” (3 points), and “strongly disagree” (4 points). “1–3”, “8”, “10”, “14”, “16”, “19”, and “20” (negative points), and “4”, “7”, “9”, “11”, “13”, and “15” (positive points), with a total score of 20–80 points. Cronbach’s α coefficient was 0.803, with α coefficients for responsibility, control, and challenge dimensions being 0.764, 0.720, and 0.704, respectively [16].
2.3.4. SCSQ
Xie et al. [17] developed the SCSQ, which consists of two dimensions, positive and negative coping, with 20 entries. The scale is rated on a 4-point Likert scale, 0 points for “do not take”, one point for “occasionally take”, two points for “sometimes take”, and three points for “often take” The positive coping dimension has 12 entries with scores ranging from 0–36 points. The negative coping dimension has 8 entries with scores ranging from 0–24 points. The higher the score on a dimension, the more prominent the adoption of a particular coping style by the patient. Cronbach’s α coefficient was 0.90 [17].
2.4. Statistical analysis
Data were analyzed using SPSS 26.0 (IBM Corporation, Armonk, New York, USA). To analyze count data and composition ratios, we used the mean ± standard deviation to describe measures which conformed to a normal distribution. T-tests or one-way analysis of variance (ANOVA) tests were used to compare groups. Correlation analyses were performed using Pearson’s coefficient values, and multifactor analyses were performed using multiple linear stepwise regression. Differences were considered statistically significant at P < 0.05.