| Background:The number of hepatocellular carcinoma patients in China accounts for more than half of the world’s patients,and it is the second leading cause of tumor death,which seriously threatens people’s lives and health.Transarterial chemoembolization(TACE)is recognized as a localized hepatocellular carcinoma.One of the treatment methods,it has become the first choice for non-surgical treatment of mid-stage hepatocellular carcinoma patients.Patients still face the risk of relapse after receiving TACE treatment.Repeated TACE treatment brings great pain to the patient both physically and psychologically.Therefore,the patient has severe negative emotions such as anxiety and depression.These negative emotions lead to the decline of the patient’s body resistance,which seriously affects the patient’s treatment and recovery,and further promotes tumor recurrence,deterioration,and metastasis.However,there is no widely recognized effective intervention method for anxiety and depression in patients with hepatocellular carcinoma after TACE.An in-depth understanding of the causes and internal mechanisms of anxiety and depression in patients with hepatocellular carcinoma after TACE can provide a basis for the formulation of intervention measures.Many patients with liver cancer after TACE have psychological distress such as anxiety and depression,which are related to inappropriate emotion regulation strategies.Liver cancer brings enormous psychological pressure to patients.Avoidance is a common way for humans to face negative experiences.However,excessive use of experiential avoidance is not only ineffective,but makes people more painful.Therefore,experiential avoidance may lead to anxiety and depression.In addition to the psychological adjustment strategy,it is also related to the psychological quality of the patients.There are differences in the psychological quality and psychological adjustment ability of different individuals.Therefore,exploring the key internal resources for liver cancer patients to cope with liver cancer diagnosis and treatment,namely psychological quality and psychological adjustment factors,will help to identify effective intervention targets,formulate more precise and targeted measures,and prevent and reduce anxiety and depression.Research has shown that trait mindfulness can have a significant positive impact on an individual’s physical health,cognitive,emotional,and behavioral problems.This suggests the possibility of trait mindfulness as a protective factor for anxiety and depression and other psychological distress,and as a target for intervention,but whether trait mindfulness has a buffering effect on anxiety and depression in patients with liver cancer after TACE has not been confirmed.To explore the relationship and interaction of trait mindfulness,perceived stress,experiential avoidance,anxiety and depression,and provide a theoretical basis for the formulation of psychological interventions for patients with hepatocellular carcinoma after TACE.How to formulate a scientific and effective intervention plan according to the mediating model of anxiety and depression in patients with hepatocellular carcinoma after TACE surgery is the key to influence the effect of intervention.Using trait mindfulness,perceived stress and experiential avoidance as potential mechanisms of mindfulness,MBSR can reduce participants’stress.Experiential avoidance is the core concept of acceptance and commitment therapy.Therefore,in the scheme construction,the elements of MBSR and acceptance and commitment therapy are absorbed,and the content of cancer rehabilitation is integrated into it.In combination with the characteristics of hepatocellular carcinoma patients after TACE surgery,the web-based mindfulness intervention scheme suitable for the characteristics of hepatocellular carcinoma patients after TACE surgery is constructed.With the development of network technology,the Internet has become an important source of health-related information for cancer patients,which is time-saving,labor-saving and has good privacy.The combination of web-based technology and mindfulness to form a web-based mindfulness intervention scheme can improve the accessibility and convenience of mindfulness intervention.To explore the short-term and long-term intervention effect of web-based mindfulness intervention program on anxiety and depression in patients with hepatocellular carcinoma after TACE surgery,and explore the psychological mechanism of intervention,so as to provide theoretical and practical guidance for psychological intervention in patients with hepatocellular carcinoma after TACE surgery.Objectives:(1)To verify the intervention effect of web-based mindfulness interventions on patients with physical diseases and cancer patients based on evidence-based methods,so as to provide a basis for the selection of intervention methods for anxiety and depression in patients after TACE.(2)Through field investigation,to understand the level of anxiety and depression and related factors of hepatocellular carcinoma patients after TACE,analyze the mediating effect of empirical avoidance between anxiety and depression and perceived stress and the moderating effect of trait mindfulness,so as to provide a theoretical basis for clarifying the target of mindfulness intervention.(3)Based on the results of systematic evaluation and the mediating model of anxiety and depression in hepatocellular carcinoma patients after TACE surgery,and combined with the physical and mental characteristics of hepatocellular carcinoma patients after TACE surgery,a web-based mindfulness intervention program for hepatocellular carcinoma patients after TACE surgery was constructed.(4)according to the result of system evaluation targets,and mindfulness intervention combined with postoperative hepatocellular carcinoma patients with conventional physical and mental characteristics,build a network for postoperative hepatocellular carcinoma patients with conventional mindfulness intervention program,through a randomized controlled trial to explore the scheme of immediate and long-term intervention effect of conventional TACE postoperative patients with hepatocellular carcinoma,and explore the psychological mechanism of the intervention.(5)Through qualitative research,to understand the experience of participants,comprehensively explore the benefits of web-based mindfulness interventions,and analyze the influencing factors of participants’compliance,so as to further improve the online mindfulness intervention program and lay the foundation for the extensive promotion of mindfulness intervention.Methods:(1)Meta-analysis of the effect of web-based mindfulness interventions interventions on patients with physical health conditionsNine Chinese and English databases were systematically searched for randomised controlled trials on the effect of web-based mindfulness interventions interventions on patients with physical health conditions.The publication date was limited from the establishment of the database to November 20,2019,and the pooled standardized mean difference(SMD)was calpatientsculated using a random effects model.The intervention effect was integrated with 95%confidence interval(CI),and the effect of web-based mindfulness interventions interventions on anxiety,depression,stress,mindfulness level,quality of life,and sleep problems in patients with physical health conditions was analyzed.Forest plots are used to display the merged results.I~2was used to assess heterogeneity across studies.Funnel plots were used to assess potential publication bias.(2)The effect of perceived stress on anxiety and depression in patients with hepatocellular carcinoma after TACE:the mediating effect of experiential avoidance and the moderating effect of trait mindfulnessA cross-sectional study design was used.From October 2019 to September 2020,patients with hepatocellular carcinoma after TACE were recruited in a tertiary hospital in Jilin Province by means of convenience sampling as research subjects.Demographic sociological characteristics,anxiety and depression,perceived stress,experiential avoidance,trait mindfulness of the study subjects were investigated.Descriptive analysis was used to report the characteristics of the research subjects and the current status of anxiety and depression.Univariate analysis was used to examine whether there were differences in anxiety and depression among subjects with different characteristics,and the correlation between anxiety and depression,perceived stress,experiential avoidance,and trait mindfulness.A moderated mediation model with anxiety and depression as the dependent variable,perceived stress as the independent variable,experiential avoidance as the mediator variable,and trait mindfulness as the moderator variable was constructed using the PROCESS plug-in bias-corrected nonparametric percentile bootstrap method.For the mechanism of action of trait mindfulness,the95%confidence interval does not include 0,which means the effect is significant.(3)To construct a web-based mindfulness intervention scheme for hepatocellular carcinoma patients after TACE surgeryA mindfulness research team was established.Based on the results of systematic evaluation,the characteristics of hepatocellular carcinoma patients after TACE surgery and the influencing factors of anxiety and depression in hepatocellular carcinoma patients after TACE surgery,the first draft of the network mindfulness intervention plan for anxiety and depression in liver cancer patients after TACE surgery was constructed,and the intervention plan was revised through the expert meeting method.(4)The effect and mechanism of web-based mindfulness interventions interventions on patients with hepatocellular carcinoma after TACEAccording to the results of the systematic review,the characteristics of hepatocellular carcinoma patients after TACE,and the potential targets of mindfulness intervention,such as mindfulness,perceived stress and empirical avoidance,a web-based mindfulness intervention program for anxiety and depression of hepatocellular carcinoma patients after TACE was constructed.MBSR can reduce participants’stress,and empirical avoidance is a core concept of acceptance and commitment therapy.Therefore,in the construction of the program,the elements of mindfulness-based stress reduction therapy and acceptance and commitment therapy were incorporated into the content of mindfulness-based cancer rehabilitation,and the characteristics of hepatocellular carcinoma patients after TACE were combined to construct a web-based mindfulness intervention program suitable for liver cancer patients after TACE.A randomized controlled study design was used to select 122 patients with hepatocellular carcinoma after TACE in the interventional ward of a tertiary first-class hospital in Jilin Province.The patients were randomly assigned to the intervention group(n=61)and the control group(n=61).Through evidence-based nursing and combining with the characteristics of hepatocellular carcinoma patients after TACE,the online mindfulness-based intervention program was constructed through expert discussion.The intervention group received the mindfulness-based interventions for 6 weeks,while the control group received the routine nursing of the hospital.Participants were assessed for anxiety and depression,sleep problems,and quality of life at baseline(T0),after the intervention(T1),1 month after the intervention(T2),and 3 months after the intervention(T3).Trait mindfulness,perceived stress,and empirical avoidance were assessed at baseline and after the intervention.Generalized estimating equation(GEE)was used to evaluate the difference of outcome indicators between the intervention group and the control group during the intervention period,and to test the effect of the intervention.Then,according to the sequential test and analysis ideas of Baron and Kenny,we explored whether trait mindfulness,perceived stress and empirical avoidance were the targets of mindfulness intervention.intention-to-treat analysis was used in all analyses.(5)Qualitative research on the experience of online mindfulness intervention in patients with hepatocellular carcinoma after TACE:The purposeful sampling method was used to select interviewees from patients with hepatocellular carcinoma after TACE who completed the online mindfulness intervention,and personal semi-structured interviews were conducted for them.The sample size was determined by information saturation.The interview outline mainly involved the participants’positive and negative experiences during the intervention process,the factors that facilitated and hindered activity compliance,and qualitative content analysis was used for data analysis.Result:(1)Meta-analysis of the intervention effect of web-based mindfulness interventions interventions on patients with physical health conditions:A total of 13 literatures were included.Web-based mindfulness interventions interventions can improve the anxiety,depression and stress of patients with physical health conditions,improve their trait mindfulness,and have no significant impact on quality of life and sleep problems.Subgroup analysis showed that internet-based mindfulness intervention could improve anxiety,depression,stress,and sleep problems in cancer patients,and improve their trait mindfulness,with no significant improvement in quality of life.(2)The effect of perceived stress on anxiety and depression in patients with hepatocellular carcinoma after TACE:the mediating effect of experiential avoidance and the moderating effect of trait mindfulness.A total of 458 patients with hepatocellular carcinoma after TACE were investigated,and the score of anxiety and depression after TACE was(14.11±4.515),the anxiety score was 7.10±2.563,the depression score was 7.01±2.597,the incidence of anxiety was 40.2%,and the incidence of depression was 48.7%.In general data and disease data,different educational levels,family economic burden,presence or absence of liver cirrhosis and Child classification had significant effects on anxiety and depression levels in patients with hepatocellular carcinoma after TACE(all p<0.05).Spearman correlation analysis showed that anxiety and depression were positively correlated with perceived stress and experiential avoidance(both p<0.001),and there was a positive correlation between perceived stress and experiential avoidance(p<0.001).Trait mindfulness was associated with anxiety,depression,perceived stress,Experiential avoidance was negatively correlated(p<0.001).The mediation model test showed that experiential avoidance partially mediates the effect of perceived stress on anxiety and depression,with a mediating effect value of 0.041 and an effect size of 23.98%.Trait mindfulness moderated the relationship between perceived stress and experiential avoidance in the mediation model[Β=-0.029,95%CI=(-0.038,-0.021)],and also moderated the relationship between experiential avoidance and anxiety and depression in the mediation model effect(Β=-0.005,95%CI=[-0.009,-0.001]),and also had a moderating effect on the relationship between perceived stress and anxiety and depression in the mediation model[Β=-0.011,95%CI=(-0.014,-0.007)].(3)To construct a web-based mindfulness intervention scheme for hepatocellular carcinoma patients after TACE surgeryA total of 5 experts were invited to a meeting for discussion,and expert opinions were formed.The intervention plan was revised according to the expert opinions,and the specific way of network-based intervention was determined.There were six themes in the intervention plan:(1)Mindfulness and liver cancer,self-acceptance;(2)Cancer and stress,cognitive dissociation;(3)Identify avoidant response and self-awareness;(4)Mindfulness enters life and focuses on the present moment;(5)Unselective awareness,clear value;(6)Thanksgiving life,commitment to action.The content of the intervention is presented in the form of a wechat public account.The duration of the intervention was 6 weeks,at least 5 days per week,and the total duration of study and practice was 30 to 40 minutes per day.(4)The effect and mechanism of web-based mindfulness interventions interventions on patients with hepatocellular carcinoma after TACEGEE was used to analyze the effect of web-based mindfulness interventions interventions on anxiety,depression,quality of life and sleep problems in patients with hepatocellular carcinoma after TACE.In terms of anxiety and depression,the time effect was statistically significant(p=0.001),indicating that the anxiety and depression scores of the two groups of patients changed over time.The group×time interaction effect was significant(p=0.002),indicating that the anxiety and depression scores of the intervention group and the control group had different trends over time at the four time points.In terms of quality of life,the quality of life scores between the two groups at the four time points of T0,T1,T2 and T3 were all insignificant(p>0.05).There were no statistically significant differences in the scores and the changes in the scores between the two groups at the four time points.In terms of sleep problems,the inter-group effects of sleep problem scores at T0,T1,T2 and T3 were significant(p=0.035),indicating that there were significant differences in sleep problem scores between the two groups.The time effect was significant(p=0.001),indicating that patients’sleep problem scores changed over time.The time×intergroup interaction effect was significant(p=0.011),indicating that the sleep problem scores of the intervention group and the control group had different trends over time at the four time points.GEE was used to analyze the effect of web-based mindfulness interventions interventions on the mediating variables trait mindfulness,perceived stress and experiential avoidance.In terms of trait mindfulness,the time effect of trait mindfulness scores in the two groups at T0 and T1 was significant(p<0.001),and the time×group interaction effect was significant(p=0.006),indicating that online mindfulness intervention can significantly improve the lever of the trait mindfulness of intervention group.In terms of perceived stress,the time effect was significant(p=0.024),indicating that the patients’perceived stress scores changed over time.The time×group interaction effect was significant(p=0.010),indicating that web-based mindfulness interventions interventions can significantly reduce the perceived stress level of the intervention group.For experiential avoidance,the time effect was significant(p=0.011),indicating that patients’experiential avoidance scores changed over time.The time×group interaction effect was significant(p<0.001),indicating that web-based mindfulness interventions interventions can significantly reduce experiential avoidance in the intervention group.The mediation effect analysis showed that after adding trait mindfulness,perceived stress and experiential avoidance to the GEE model with anxiety and depression as the dependent variable,trait mindfulness had a significant effect on anxiety and depression(B=-0.179,p<0.001),and perceived stress had a significant effect(B=-0.179,p<0.001).The effect on anxiety and depression was significant(B=0.240,p<0.001),the effect of experiential avoidance on anxiety and depression was significant(B=0.097,p<0.001),and the direct effect of intervention on anxiety and depression(group×time interaction effect)was no longer significant(p=0.139),indicating that the effect of the intervention on anxiety and depression was caused by changes in trait mindfulness,perceived stress,and experiential avoidance.After adding trait mindfulness,perceived stress and experiential avoidance to the GEE model with sleep problems as the dependent variable,the results showed that the effect of trait mindfulness on sleep problems was not significant(B=-0.039,p=0.079),while perceived stress had no significant effect on sleep problems(B=-0.039,p=0.079).The effect of problems was significant(B=0.217,p<0.001),the effect of experiential avoidance on sleep problems was not significant(B=0.016,p=0.631),and the direct effect of intervention on sleep problems(interaction effect of group×time)was no longer significant(p=0.521),indicating that the effect of the intervention on sleep problems was mainly caused by changes in perceived stress.(5)Qualitative research on the experience of online mindfulness intervention for hepatocellular carcinoma patients after TACE:five main categories were finally formed:mindfulness mentality,improvement of physical discomfort,resistance of mindfulness practice,support and encouragement,accessibility and convenience.The main category 1 includes three general categories:acceptance,calm and mood improvement.The main category 2 includes four general categories:improvement of sleep,relief of pain,relief of digestive tract symptoms and increase of activity.Main category 3:The resistance of mindfulness practice includes five general categories:lack of effect,illness,restriction of equipment use,difficulty in focusing and lack of motivation to practice.Support and encouragement includes two general categories:social support,supervision and guidance;Category 5 Accessibility and convenience contains 2general categories,namely,restoring a sense of balance to life,and practicing features.Conclusions:(1)Patients with hepatocellular carcinoma,after TACE have severe anxiety and depression.Experiential avoidance partially mediates the effect of perceived stress on anxiety and depression.Trait mindfulness has a buffering effect on anxiety and depression.(2)Internet mindfulness intervention can improve anxiety and depression,sleep problems,perceived stress and experiential avoidance in patients with hepatocellular carcinoma,and improve trait mindfulness.Therefore,Internet mindfulness intervention is a suitable psychological intervention method for hepatocellular carcinoma,patients after TACE.(3)Internet mindfulness intervention can reduce anxiety and depression by improving trait mindfulness,reducing perceived stress and experiential avoidance in patients with hepatocellular carcinoma after TACE.Improve sleep problems by reducing perceived stress.(4)Participants of online mindfulness intervention subjectively felt the benefits of psychology and body.In the future promotion,attention should be paid to strengthening the promoting factors of intervention compliance,avoiding the blocking factors,and improving the formulation and implementation of the program. |
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