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The Body Image and Relationships Scale: Development and Validation of a Measure of Body Image in Female Breast Cancer Survivors

Julia M. Hormes, Leslie A. Lytle, Cynthia R. Gross, Rehana L. Ahmed, Andrea B. Troxel, Kathryn H. Schmitz

From the Department of Psychology; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA; Division of Epidemiology and Community Health; and College of Pharmacy and School of Nursing, University of Minnesota, Minneapolis, MN

Corresponding author: Kathryn H. Schmitz, PhD, 921 Blockley Hall, 423 Guardian Dr, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA 19104-6021; e-mail: schmitz{at}mail.med.upenn.edu

	ABSTRACT

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Purpose A self-report measure of body image in female breast cancer survivors, the Body Image and Relationships Scale (BIRS), was developed to address attitudes about appearance, health, physical strength, sexuality, relationships, and social functioning following treatment.

Methods The 32-item measure, generated by expert consensus and revised based on focus group feedback, was administered to 95 female breast cancer participants twice within 1 to 2 weeks. Test-retest reliability, internal consistency, and validity of the measure were assessed using standard-scale construction techniques. The structure of the proposed measure was evaluated using exploratory factor analysis. Associations of the resulting factors and other variables were assessed using extreme groups analyses.

Results The BIRS had satisfactory test-retest reliability and internal consistency. Principal axis factoring revealed three factors: (1) health and strength, (2) social barriers, and (3) appearance and sexuality. Correlations of the subscales with standardized measures of related constructs were significant and in the anticipated directions. Extreme groups analyses suggested associations between less physical activity and more impairment on factors 1 and 3, premenopausal status at first diagnosis and more impairment on factor 2, and younger age at the time of survey administration and more impairment on factor 3.

Conclusion The proposed scale demonstrated satisfactory reliability and internal consistency. Factor analysis revealed three subscales with coherent item content and differential associations with measures of activity level, menopause status, and age. Observed relationships with other measures support convergent and divergent validity. Results suggest that the proposed scale is useful for clinical and research applications.

	INTRODUCTION

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The construct of body image has been evoked in relation to the physical and psychological changes associated with the treatment of breast cancer. Surgical therapies for breast cancer, including lumpectomy, mastectomy, and axillary lymph node dissection may be disfiguring and often traumatic. Mastectomies and reconstructive surgeries predict body image problems, especially in younger and sexually active women.^1,2 Younger women who attribute more importance to body image than older patients tend to report lower body image satisfaction and poorer psychosocial adjustment after surgery.³

Body image is an important predictor of outcome, with measures of body image after breast cancer treatment explaining 59% of the variance in psychosocial adjustment.³ More positive body image perception correlates with higher self-efficacy in coping with breast cancer and its treatment,⁴ whereas heightened concern with body integrity predicts elevated distress, social disruption, and deterioration in feelings of sexual desirability.^5,6

Breast cancer patients frequently experience sleep disturbances,⁷ and chemotherapy and radiotherapy can cause increased levels of fatigue.^8,9 A decrease in sexual pleasure and dyspareunia was reported primarily in patients who underwent chemotherapy and radiotherapy, as well as surgery.¹⁰ A history of chemotherapy also has been associated with several late effects in breast cancer survivors. For example, chemotherapy and other postsurgical adjuvant therapies, such as tamoxifen, may cause menopausal symptoms among those diagnosed premenopausally.¹¹ Decreased sexual desire has been reported by women diagnosed with early-stage as well as metastatic breast cancer, and is related to a high degree of concern about body integrity.^6,12

Overall, previous research suggests that breast cancer treatment significantly impacts body image in female patients, and influences important long-term outcomes, including quality of life, sexuality, and psychosocial adjustment in survivors. However, to date, a disease-specific measure of body image in breast cancer survivors has not been developed. The need for such an instrument was noted in a completed exercise intervention study¹³ in which participating breast cancer survivors reported, anecdotally, that they experienced changes in body image as it related to social barriers, sense of strength and health, appearance, and sexuality. These survivors expressed frustration that the quality-of-life surveys administered pre- and postintervention did not adequately capture these important issues. When funded to conduct another exercise intervention study in breast cancer survivors (the ongoing Physical Activity and Lymphedema [PAL] trial), the researchers took the opportunity to develop a new survey to address these issues. This report describes the development and evaluation of the Body Image and Relationships Scale (BIRS) currently in use for the ongoing PAL trial.

	METHODS

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Participants
Twenty-one female breast cancer survivors were recruited through flyers posted at oncology clinics, notices placed in newsletters of cancer support organizations, and e-mails and letters sent to the address lists of local breast cancer support organizations (eg, the local Susan G. Komen chapter) to participate in focus groups to evaluate the initial version of a survey developed by the researchers.

The 96 test-retest survey respondents were female long-term breast cancer survivors, recruited the same way as the focus groups. Participants were mostly white (95.8%), ranging in age from 37 to 77 years (mean, 56.9 years). All respondents had been diagnosed 5 to 15 years before participating in the study and self-reported being currently cancer free. Ninety-five of the participating women completed both surveys within 2 weeks.

Focus-group participants received a $20 gift card for their 2-hour time commitment. Participants in the test-retest reliability assessment received a $15 gift card. All participants provided written informed consent for participation. The study was reviewed and approved by a University of Minnesota (Minneapolis, MN) human subjects protection program committee. All data collection and participant interaction took place at the University of Minnesota. The data analysis was conducted with a de-identified data set at the University of Pennsylvania.

Survey Items
A literature review failed to uncover any existing instruments that address the body image, appearance, and sexuality issues that breast cancer survivor participants in the completed study anecdotally reported had changed as a result of 6 months of twice-weekly weight training.¹³ A list of these anecdotal statements was reviewed by K.H.S., C.R.G., L.A.L., and R.L.A. in designing an initial survey aimed at capturing the experiences of long-term breast cancer survivors with respect to body image. At each focus group, the participants completed the survey and then discussed the survey in groups of four to eight women. The discussions were led by a clinical psychologist with focus-group expertise and a background in conducting behavioral-health interventions. The questions used by the focus groups during the discussions included:(1) Which questions made you think the most? (2) Tell me about sections or questions that were challenging for you. (3) Talk about questions you wish had been asked that were not asked. (4) How did you figure out the answers to the survey questions? (5) Tell me about questions you wish had not been asked. Why? (6) What changes in the survey would make it easier for you to comfortably, confidently complete the survey?

Preliminary versions of the questionnaire were revised with the help of the focus group participants. For example, questions about the impact of hot flashes on body image, social barriers, and sexuality were added based on focus group feedback.

The revised survey was sent to five more breast cancer survivors, who completed the survey and underwent a brief telephone interview to answer questions similar to those used in the focus group discussions. Feedback from these five breast cancer survivors indicated that the survey addressed issues of importance to breast cancer survivors, that instructions and wording were clear, and that they felt comfortable answering all questions and were glad to have been asked about the issues in the survey. Based on these interviews, the only changes made were formatting changes.

The resulting set of 32 items was administered via mail to the 96 study participants. Respondents were instructed to indicate on a five-point bipolar rating scale their agreement with each item (end points: 1 = disagree strongly, and 5 = agree strongly). Total scores were calculated by summing responses for all items. The scoring of individual items was reversed where appropriate so that higher scores indicated more impairment.

As part of the larger PAL trial, respondents also provided basic demographic information and completed a battery of additional measures (Table 1), including the Coopersmith Self-Esteem Inventory, Pittsburgh Sleep-Quality Index, Fatigue Symptom Inventory, Medical Outcome Study Short Form and Social Support Scale, Pearlin's Social Mastery Scale, Life Orientation Test, Happiness Scale, Temporal-Satisfaction-with-Life Scale, Life Orientation Test, and a Quality-of-Life rating scale. These measures were designed to capture the various physiological and psychological sequelae of cancer diagnoses and treatments; all measures have admirable psychometric properties, including responsiveness to change, are readily scored and interpreted, may be self-administered via the mail, and are appropriate for adults across a broad spectrum of health states. All measures were completed twice, at the same time as participants completed the BIRS measure.

Data were analyzed using SPSS software (SPSS Inc, Chicago, IL). Test-retest reliability and internal consistency were assessed by calculating test-retest correlations and Cronbach's .²⁸ Data were subjected to both principal components analysis and principal axis factoring, followed by Varimax and direct Oblimin rotations. Correlations between scores on the proposed measure and the additional instruments completed by participants were examined to assess convergent and divergent validity. ² tests were used to conduct extreme groups analyses, comparing participants scoring in the low versus high ranges on the BIRS along a number of relevant variables.

	RESULTS

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Demographics
A majority of participants were living with a partner (67.7%), but without children (72.0%). About two thirds of respondents had a college degree (60.4%). A majority of respondents reported an absence of current treatment for psychological difficulties (94.8%). Only 27.1% of respondents experienced any physical or mental health events during the year preceding the survey; 16.7% of respondents reported significant physical- or mental-health events. Most participants (80.2%) were currently physically active. Participants who exercised three times or more per week were less likely to report any physical or mental health events during the previous year (22.1% v 47.1%; ² = 4.45; P = .07). At the time of their first diagnosis, 41.7% of respondents were premenopausal, 39.6% were postmenopausal, and 17.7% were perimenopausal. About two-thirds of respondents (61.5%) had experienced hot flashes and/or night sweats during the previous year. There was no significant difference between respondents who exercised more or less than three times a week in the prevalence of hot flashes.

Reliability and Internal Consistency
All 32 questionnaire items showed satisfactory test-retest reliability, ranging from Spearman = 0.41 to 0.80 (mean, 0.65; P .001 for all items). Seven survey items achieved a test-retest reliability below 0.60. Cronbach's was .94 for both administrations of the survey items. No single item, if eliminated, would have significantly increased the value of Cronbach's . Therefore, all 32 items were retained for additional analyses.

Principal Axis Factoring
The 32 items of the BIRS were subjected to principal axis factoring. Before performing the analysis, the suitability of the data for factoring was assessed. Inspection of the correlation matrix revealed the presence of many coefficients of 0.30 and above. The Kaiser-Meyer-Oklin value was 0.84, and the Bartlett's test of sphericity reached statistical significance, supporting the factorability of the correlation matrix.^29,30

Principal axis factoring revealed the presence of eight factors with eigne values exceeding one; inspection of the scree plot revealed a clear break after the third factor. Based on Cattell's scree test, three factors were retained for further investigation.³¹ To aid the interpretation of these three factors, Varimax (orthogonal) rotation was performed. The rotated solution (Table 2) revealed the presence of simple structure, with all factors showing a number of strong loadings, and all but one variable loading substantially (at 0.40 or above) on only one component; the exception was item 20: "Sexual activity was an important part of my life," which loaded at only 0.28 on one factor. The three-factor solution explained a total of 52.9% of the variance, with factor 1 contributing 35.3%, factor 2 contributing 9.2%, and factor 3 contributing 8.4%. The three factors were significantly and positively correlated (Table 3). Results of another rotation, the direct Oblimin (oblique), were largely consistent with those described here. The only exception was item 5: "I felt like I had some control over how healthy I was," which loaded about equally onto factors 1 and 3.

Similar results were obtained from a principal components analysis, which also indicated three factors; the one difference was that item 5: "I felt like I had some control over how healthy I was" loaded on factor 1 instead of factor 3.

Convergent and Divergent Validity
Convergent and divergent validity was assessed by correlating the three factors of the BIRS with the additional instruments administered to the participants in the PAL trial (Table 1). Correlations were based on the first of two rounds of administration and were in the expected directions and statistically significant (with r values ranging from –0.61 to –0.24, and 0.32 to 0.57). These correlations (Table 4) were not high enough to suggest a significant degree of conceptual overlap. In terms of divergent validity, the three subscales shared, on average, only 17.7% of the variance with other standardized instruments, and ranged from 5.8% to 42.3%.

Impairment in social functioning, as indicated by higher scores on factor 2, social barriers, correlated negatively and strongly with measures of self-esteem, quality of life, and life satisfaction, and less strongly with the optimism subscale of the Life Orientation Test, and happiness and social support scores. Factor 2 correlated strongly and positively with fatigue, and weakly with pessimism and sleep quality.

Finally, high scores on factor 3 and impairment in the area of appearance and sexuality correlated strongly and inversely with measures of self-esteem, life satisfaction, and optimism. Negative correlations with social support, quality of life, and happiness were weaker, but still significant. Factor 3 correlated strongly and positively with scores on measures of personal mastery and pessimism, and somewhat more weakly and positively with measures of fatigue and sleep quality.

Extreme Groups Analyses
Scores on the three subscales were divided into low and high scores at the respective midpoints on the scale. Extreme groups analyses were conducted using ² tests, comparing women of different ages at survey administration, different menopause status at first diagnosis, and varying levels of activity in terms of their scores on each of the three subscales.

Respondents who reported currently exercising three times per week or more were significantly more likely to score lower on factor 1 strength and health (² = 5.51; P = .03), indicating less impairment in this domain compared with women who exercised less frequently (63.2% v 31.3% scoring in the low range). Participants who reported higher levels of physical activity were also more likely to score lower on factor 3 appearance and sexuality (² = 4.30; P = .06), suggesting less impairment than women exercising less than three times per week (55.4% v 27.8% scoring in the low range).

Peri- and postmenopausal respondents scored significantly lower on factor 2, social barriers (² = 8.15; P = .004), indicating less impairment in social functioning compared with participants who were premenopausal at the time of their first diagnosis (97.9% v 78.9% scoring in the low range on factor 2).

Women younger than age 50 years at the time of survey administration were more likely to score higher on appearance and sexuality (² = 4.62; P = .06), suggesting more impairment in this area of functioning compared with women older than 60 years of age (65.0% v 31.8% scoring in the high range).

	DISCUSSION

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This study aimed at developing a measure that captures experiences related to appearance, health, physical strength, sexuality, relationships, and social functioning that are unique to women diagnosed with, and treated for, breast cancer. These important issues had not been addressed in existing surveys. The proposed measure adequately reflects the experience of female breast cancer survivors, has acceptable psychometrics, and lends itself to future research in the field.

Results suggest that the BIRS is an internally consistent, three-factor measure with good test-retest reliability. The scale produced expected correlations with measures of self-esteem, quality of life, personal mastery, and satisfaction with life, yet had good discriminant validity. Feedback from focus groups and respondents suggests good content validity, in that women felt the BIRS captured salient aspects of their experiences with regard to body image.

Scales of the BIRS discriminated in predictable ways between women of different ages, menopause status, and levels of physical activity. Younger age was related to more impairment in sexual functioning and lower satisfaction with physical appearance. Having been peri- or postmenopausal at the time of the first diagnosis was related to less impairment in social functioning. Finally, women with higher levels of physical activity reported less impairment in physical strength and perceived control over their health.

Two million breast cancer survivors are alive in the United States today. Previous research has focused primarily on treatment outcomes, such as rates of survival and recurrences; more recently, research has included the study of long-term effects of breast cancer treatment on outcomes such as quality of life.^32-34 Research on psychosocial outcomes in breast cancer survivors has traditionally utilized broad measures of quality of life, which generally suggests adequate psychological and social functioning. However, anecdotal evidence, such as findings from our focus groups and a recent review,³⁵ indicates that specific aspects of psychosocial adjustment and functioning after breast cancer diagnosis and treatment has not been appropriately captured by existing measures. Specifically, it appears that body image, sexuality, and appearance are all major psychosocial concerns for survivors that require disease-specific measures.

As illustrated in this article, surgical and other treatments for breast cancer cause lasting changes in survivors’ physical appearance, sexuality, subjective well-being, and self-esteem. These changes can lead to impaired functioning in intimate relationships, lower perceived social support, and limited social activity. The BIRS addresses these aspects of survivorship and will likely provide a useful tool in future research on this topic, including as an outcome measure in studies investigating psychosocial functioning in terms of body image and relationships in breast cancer survivors, such as the ongoing PAL trial.

	AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

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The author(s) indicated no potential conflicts of interest.

	AUTHOR CONTRIBUTIONS

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Conception and design: Leslie A. Lytle, Cynthia R. Gross, Rehana L. Ahmed, Kathryn H. Schmitz

Administrative support: Rehana L. Ahmed, Kathryn H. Schmitz

Provision of study materials or patients: Cynthia R. Gross, Rehana L. Ahmed, Kathryn H. Schmitz

Collection and assembly of data: Cynthia R. Gross, Rehana L. Ahmed, Kathryn H. Schmitz

Data analysis and interpretation: Julia M. Hormes, Leslie A. Lytle, Cynthia R. Gross, Rehana L. Ahmed, Andrea B. Troxel, Kathryn H. Schmitz

Manuscript writing: Julia M. Hormes, Leslie A. Lytle, Cynthia R. Gross, Rehana L. Ahmed, Andrea B. Troxel, Kathryn H. Schmitz

Final approval of manuscript: Leslie A. Lytle, Cynthia R. Gross, Rehana L. Ahmed, Andrea B. Troxel, Kathryn H. Schmitz

	NOTES

 
Supported by Grant No. R01-CA106851 from the National Cancer Institute.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

	REFERENCES

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Submitted September 6, 2007; accepted November 16, 2007.

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This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hormes, J. M. Articles by Schmitz, K. H. Search for Related Content PubMed PubMed Citation Articles by Hormes, J. M. Articles by Schmitz, K. H. Social Bookmarking                            What's this?