مدل‌یابی کیفیت زندگی بر اساس استرس ادراک شده و سبک زندگی ارتقا دهنده سلامت با میانجی‌گری انعطاف‌پذیری شناختی در بیماران مبتلا به بدخیمی‌های خونی

فاطمه  حاجی فتحعلی; سوزان امامی پور; لیدا  لیل آبادی; مرجان  علیزاده

Authors

Fatemeh Haji Fathali Department of Psychology, CT.C., Islamic Azad University, Tehran, Iran Author https://orcid.org/0009-0003-3730-9271
Susan Emamipour Department of Psychology, CT.C., Islamic Azad University, Tehran, Iran Author https://orcid.org/0000-0002-5656-6615
Lida Leilabadie Department of Psychology, CT.C., Islamic Azad University, Tehran, Iran Author https://orcid.org/0009-0009-5316-3691
Marjan Alizadeh Department of Psychology, CT.C., Islamic Azad University, Tehran, Iran Author https://orcid.org/0000-0002-1772-3518

Keywords:

quality of life, perceived stress, health-promoting lifestyle, cognitive flexibility, hematologic malignancies

Abstract

Objective: The present study aimed to structurally model the quality of life of patients with hematologic malignancies based on perceived stress and health-promoting lifestyle, mediated by cognitive flexibility.

Methodology: This correlational study employed structural equation modeling. The statistical population consisted of patients with hematologic malignancies who were candidates for hematopoietic stem cell transplantation at Ayathullah Taleghani Hospital in Tehran, from Marchto November 2025. Purposeful samplingwas used, and 260 patients (135 men and 125 women) participated. Research instruments included the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), Perceived Stress Scale (PSS), Health-Promoting Lifestyle Profile (HPLP-II), and Cognitive Flexibility Inventory (CFI). Data were analyzed using SPSS version 28 and Amos version 24 with structural equation modeling.

Findings: Results showed that perceived stress had a significant direct negative effect on quality of life (β = -0.415, p < 0.001). Health-promoting lifestyle had the strongest significant direct positive effect (β = 0.517, p < 0.001) and a significant positive indirect effect through the mediation of cognitive flexibility (β = 0.131, p = 0.002) on quality of life. Cognitive flexibility also had a significant direct positive effect on quality of life (β = 0.351, p < 0.001), but its mediating role in the relationship between perceived stress and quality of life was not significant (β = 0.044, p = 0.245). The proposed model had good fit and explained 67% of the variance in quality of life.

Conclusion: Health-promoting lifestyle and cognitive flexibility act as key protective factors, while perceived stress serves as the main vulnerability factor in the quality of life of patients with hematologic malignancies. Interventions aimed at promoting health-oriented behaviors, strengthening cognitive flexibility, and stress management can help improve the quality of life in these patients.

Downloads

Download data is not yet available.

References

Arch, J. J., Mitchell, J. L., Genung, S. R., Fisher, R., Andorsky, D. J., & Stanton, A. L. (2019). A randomized controlled trial of a group acceptance-based intervention for cancer survivors experiencing anxiety at re-entry ('Valued Living'): study protocol. BMC Cancer, 19(1), 89. https://doi.org/10.1186/s12885-019-5289-x

Belsky, J., & Pluess, M. (2013). Beyond risk, resilience, and dysregulation: Phenotypic plasticity and human development. Development and psychopathology, 25(4pt2), 1243-1261. https://doi.org/https://doi.org/10.1017/S095457941300059X

Berdida, D. J. E., Lopez, V., & Grande, R. A. N. (2023). Nursing students' perceived stress, social support, self‐efficacy, resilience, mindfulness and psychological well‐being: A structural equation model. International Journal of Mental Health Nursing, 32(5), 1390-1404. https://doi.org/https://doi.org/10.1111/inm.13179

Blaney, J., Lowe‐Strong, A., Rankin‐Watt, J., Campbell, A., & Gracey, J. (2013). Cancer survivors' exercise barriers, facilitators and preferences in the context of fatigue, quality of life and physical activity participation: a questionnaire–survey. Psycho‐oncology, 22(1), 186-194. https://doi.org/https://doi.org/10.1002/pon.2072

Borsati, A., Murri, A., Natalucci, V., Cerulli, C., Barbieri, E., Lucertini, F., Lanza, M., Parisi, A., Galvani, C., & Buono, P. (2025). The Effect of Exercise-Based Interventions on Health-Related Quality of Life of Patients with Hematological Malignancies: A Systematic Review and Meta-Analysis. Healthcare, https://doi.org/https://doi.org/10.3390/healthcare13050467

Calderon, C., Gustems, M., Galán-Moral, R., Muñoz-Sánchez, M. M., Ostios-García, L., & Jiménez-Fonseca, P. (2024). Fear of Recurrence in Advanced Cancer Patients: Sociodemographic, Clinical, and Psychological Correlates. Cancers (Basel), 16(5). https://doi.org/10.3390/cancers16050909

Cella, D. F. (1994). Quality of life: concepts and definition. Journal of pain and symptom management, 9(3), 186-192. https://doi.org/https://doi.org/10.1016/0885-3924(94)90129-5

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of health and social behavior, 385-396. https://doi.org/https://doi.org/10.2307/2136404

Dehghan, M., Namjoo, S., Zarei, A., Tajalli, S., & Bahrami, N. (2020). The relationship between cognitive flexibility and quality of life in cancer patients: The mediating role of mindfulness. Journal of Psychosocial Oncology Research & Practice, 2(4). https://doi.org/https://doi.org/10.1097/OR9.0000000000000031

Dennis, J. P., & Vander Wal, J. S. (2010). The Cognitive Flexibility Inventory: Instrument Development and Estimates of Reliability and Validity. Cognitive Therapy and Research, 34(3), 241-253. https://doi.org/10.1007/s10608-009-9276-4

El-Jawahri, A., Nelson-Lowe, M., VanDusen, H., Traeger, L., Greer, J. A., Chen, Y.-B. A., Lee, S. J., & Temel, J. S. (2021). A randomized controlled trial of a supportive care mobile application to improve symptoms and quality of life in patients undergoing hematopoietic cell transplantation. Journal of Clinical Oncology, 39(15). https://doi.org/https://doi.org/10.1200/JCO.2021.39.15_suppl.12002

Esser, P., Kuba, K., Mehnert, A., Johansen, C., Hinz, A., Lordick, F., & Götze, H. (2018). Quality of life in survivors of hematological malignancies stratified by cancer type, time since diagnosis and stem cell transplantation. European journal of haematology, 101(3), 340-348. https://doi.org/https://doi.org/10.1111/ejh.13104

Gerges, C., Pistritto, A.-M., Gerges, M., Friewald, R., Hartig, V., Hofbauer, T. M., Reil, B., Engel, L., Dannenberg, V., & Kastl, S. P. (2023). Left ventricular filling pressure in chronic thromboembolic pulmonary hypertension. Journal of the American College of Cardiology, 81(7), 653-664. https://www.jacc.org/doi/abs/10.1016/j.jacc.2022.11.049

González-Fernández, S., & Fernández-Rodríguez, C. (2019). Acceptance and commitment therapy in cancer: review of applications and findings. Behavioral Medicine, 45(3), 255-269. https://doi.org/https://doi.org/10.1080/08964289.2018.1452713

Hair Jr, J. F., Anderson, R. E., Tatham, R. L., & Black, W. C. (1995). Multivariate data analysis with readings. Anderson - Google Books

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy (Vol. 6). New York: Guilford Press.

Holzner, B., Kemmler, G., Kopp, M., Moschen, R., Schweigkofler, H., Dünser, M., Margreiter, R., Fleischhacker, W. W., & Sperner-Unterweger, B. (2001). Quality of life in breast cancer patients--not enough attention for long-term survivors? Psychosomatics, 42(2), 117-123. https://doi.org/10.1176/appi.psy.42.2.117

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. In (pp. 1913-1915). Springer Publishing Company.

LeBlanc, T. W., Ritchie, C. S., Friedman, E., Bull, J., & Kamal, A. H. (2020). Quality of life in patients with hematologic malignancies: A systematic review and meta-analysis. Blood Advances, 4(19), 4795-4807. https://doi.org/https://doi.org/10.1182/bloodadvances.2020002942

Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common sense representation of illness danger. In S. Rachman (Ed.), Contributions to medical psychology Pergamon Press.

Mikolaskova, I., Zvarik, M., Kollarik, B., & Hunakova, L. (2025). Heart Rate Variability and Perceived Stress Relations Differ Between First-Diagnosed and Recurrent Bladder Cancer Patients. Bratislava Medical Journal, 126(10), 2737-2746. https://doi.org/10.1007/s44411-025-00289-0

Mohammadi Zeidi, I., Pakpour Hajiagha, A., & Mohammadi Zeidi, B. (2011). J Mazandaran Univ Med Sci 20(1), 102-113. http://jmums.mazums.ac.ir/article-1-955-fa.html

Mulatie, Z., Berta, D. M., Gedefie, A., Ebrahim, H., Eshetu, B., Gessese, T., Tilahun, M., Ali, S., Debash, H., Kassa, Y., & Alemayehu, E. (2025). Prevalence of hematological malignancies in Africa: A systematic review and meta-analysis. Scientific Reports, 15(1), 9471. https://doi.org/10.1038/s41598-025-94428-w

Nejat, S., Montazeri, Holakouie Naieni, K. M., K, & Majdzadeh, S. R. (2006). The World Health Organization quality of Life (WHOQOL-BREF) questionnaire: Translation and validation study of the Iranian version. Journal of School of Public Health and Institute of Public Health Research, 4(4), 1-12. http://sjsph.tums.ac.ir/article-1-187-fa.html

Nickerson, A., Hoffman, J., Keegan, D., Kashyap, S., Tricesaria, D., Pestalozzi, Z., Argadianti Rachmah, R., Nandyatama, R., Khakbaz, M., & Nilasari, N. (2022). Context, coping, and mental health in refugees living in protracted displacement. Journal of traumatic stress, 35(6), 1769-1782. https://doi.org/https://doi.org/10.1002/jts.22885

Papathanasiou, I. V., Kelepouris, K., Valasiadis, D., Kaba, E., Tzenalis, A., & Fradelos, E. C. (2020). Quality of life of patients with hematological malignancies: A systematic review. Hematology Reports, 12(3), 75-85. https://doi.org/https://doi.org/10.4081/hr.2020.8575

Ristevska-Dimitrovska, G., Filov, I., Rajchanovska, D., Stefanovski, P., & Dejanova, B. (2015). Resilience and Quality of Life in Breast Cancer Patients. Open Access Maced J Med Sci, 3(4), 727-731. https://doi.org/10.3889/oamjms.2015.128

Safaei, M., & Shokri, O. (2014). Assessing stress in cancer patients: Factorial validity of the perceived stress scale in Iran. https://sid.ir/paper/235804/en

Sallman, D. A., Chaudhury, A., Saeed, H., & Zhang, L. E. (2025). Handbook of hematologic malignancies. Springer Publishing Company.

Shareh, H., Farmani, A., & Soltani, E. (2014). Investigating the reliability and validity of the Cognitive Flexibility Inventory (CFI-I) among Iranian university students. Practice in Clinical Psychology, 2(1), 43-50. http://jpcp.uswr.ac.ir/article-1- 163-en.html

Shuai, J., Cui, Y., Zhou, F., Yang, W., Ma, Y., & Yan, Y. (2024). Health related quality of life in pediatric hematological malignancies patients and survivors: A meta-analysis of comparative studies. Journal of Psychosomatic Research, 177, 111568. https://doi.org/https://doi.org/10.1016/j.jpsychores.2023.111568

Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians, 71(3), 209-249. https://doi.org/https://doi.org/10.3322/caac.21660

Walker, S. N., Sechrist, K. R., & Pender, N. J. (1987). The Health-Promoting Lifestyle Profile: development and psychometric characteristics. Nurs Res, 36(2), 76-81. https://pubmed.ncbi.nlm.nih.gov/3644262/

Wang, Y., Gong, X., Cheng, J., Wu, Y., Wang, S., Zhu, Y., Liu, C., He, F., & Xu, K. (2025). Mediating effect of illness perception between self-care ability and health-promoting behaviors among patients with stable coronary artery disease. PloS one, 20(2), e0316551.