the hot flush beliefs and behaviour scale for men (hfbbs-men) undergoing treatment for prostate...

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ARTICLE IN PRESSG ModelAT 6259 1–7

Maturitas xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Maturitas

jo u r n al hom ep age: www.elsev ier .com/ locate /matur i tas

he Hot Flush Beliefs and Behaviour Scale for Men (HFBBS-Men)ndergoing treatment for prostate cancer

.S. Huntera,∗, C.F. Sharpleyb,c, E. Stefanopouloua, O. Yousafa, V. Bitsikac,.R.H. Christieb,d

Institute of Psychiatry, King’s College London, UKBrain-Behaviour Research Group, University of New England, New South Wales, AustraliaCentre for Autism Spectrum Disorders, Bond University, Queensland, AustraliaGenesisCare, Queensland, Australia

r t i c l e i n f o

rticle history:eceived 10 June 2014eceived in revised form6 September 2014ccepted 29 September 2014vailable online xxx

eywords:rostate cancerot flushesight sweatsognitionsehaviourncology

a b s t r a c t

Objective: Hot flushes and night sweats (HFNS) are commonly experienced by men receiving treatmentfor prostate cancer. Cognitive behavioural therapy (CBT) has been found to be an effective treatment forHFNS in women, but cognitions and behavioural reactions to HFNS in men are under-researched. Thisstudy describes the development of the HFNS beliefs and behaviour scale for men.Methods: HFNS beliefs and behaviour items were generated from a qualitative study, from pilot interviewswith men with prostate cancer and HFNS, and from scales used for women. 118 men with prostatecancer, aged above 18, English-speaking, who had minimum of seven HFNS weekly for at least 1 month,completed the initial measure, and measures of HFNS frequency, problem rating, anxiety and depression(HADS). Principal components analyses with orthogonal rotation determined the most coherent solution.Results: Exploratory factor analysis culminated in a 17-item HFNS beliefs and behaviour scale formen (HFBBS-Men) with three subscales: (1) HFNS social context and sleep, (2) Calm/Acceptance, (3)Humour/Openness. The subscales had reasonable internal consistency (Cronbach alpha 0.56–0.83). Valid-ity was supported, by correlations between subscale 1, HFNS frequency, problem-rating and mood; menwith locally advanced cancer more likely to adopt Calm/Acceptance and those with metastatic cancer
Humour/Openness.Conclusions: Preliminary analysis of the HFBBS-Men suggests that it is a psychometrically sound instru-ment, grounded in men’s experiences. As a measure of cognitive and behavioural reactions to HF/NS, theHFBBS-Men should increase understanding of the mediators of outcomes of psychological interventions,such as CBT.
© 2014 Published by Elsevier Ireland Ltd.

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. Background

Prostate cancer (PCa) is the most common non-dermatologicalancer and the second leading cause of cancer-related death inen in the Western world [1]. While the 5-year survival rate in

he UK is generally good, PCa survivors face unwanted treatment

Please cite this article in press as: Hunter MS, et al. The Hot Flush Beliefsfor prostate cancer. Maturitas (2014), http://dx.doi.org/10.1016/j.mat

ide effects, which are particularly troublesome following andro-en deprivation therapy (ADT) and which can continue for up to–8 years [2]. These include hot flushes and night sweats (HFNS),

∗ Corresponding author at: Institute of Psychiatry, King’s College London, Depart-ent of Psychology, 5th Floor Bermondsey Wing, Guy’s Hospital, Great Maze Pond,

ondon Bridge, London SE1 9RT, UK. Tel.: +44 0207 188 0189.E-mail address: [email protected] (M.S. Hunter).

ttp://dx.doi.org/10.1016/j.maturitas.2014.09.014378-5122/© 2014 Published by Elsevier Ireland Ltd.

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gynecomastia, cognitive function, and changes in sexual function[3]. HF/NS are estimated to affect up to 80% of PCa patients [4], and

are associated with distress and reduced quality of life – particularlyaffecting sleep and physical well-being [5]. The management ofthese symptoms is problematic; a recent systematic review of treat-ments for HFNS in PCa patients concluded that few effective andwell-tolerated treatments are available, and that a priority shouldbe the development of acceptable treatments that are free from sideeffects [6]. Cognitive behaviour therapy (CBT) for HFNS has beendeveloped, by Hunter and colleagues, and found to be a safe andeffective intervention for women with troublesome HFNS, going

and Behaviour Scale for Men (HFBBS-Men) undergoing treatmenturitas.2014.09.014

through a natural menopause [7] and experiencing HFNS followingbreast cancer treatments [8,9].

HFNS in men are under researched compared to those experi-enced by menopausal women or by women following breast cancer

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dx.doi.org/10.1016/j.maturitas.2014.09.014


http://www.sciencedirect.com/science/journal/03785122

http://www.elsevier.com/locate/maturitas

mailto:[email protected]


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ARTICLEAT 6259 1–7

M.S. Hunter et al. / Ma

reatments. However, the available evidence suggests that they areenerally similar in terms of mechanisms and physiological cor-elates. For example, HFNS in both menopausal women and PCaatients are preceded by small increases in core body temperature10] and sternal skin responses during HFNS are similar in breastnd PCa patients with HFNS [11]. For both men and women withFNS, symptom frequency and problem-rating are not highly asso-iated; in fact it is problem-rating – the extent to which symptomsre bothersome and interfere with life – that is associated withelp-seeking and quality of life and is recommended as a primaryutcome measure in clinical trials [12,13].

A cognitive model of HFNS has been proposed [14] to under-tand relationships between cognitive factors, behaviours, mood,ttention and personality factors in the perception and appraisalf HFNS experienced by women. The model has been supportedy the results of a study showing that beliefs about HFNS werehe main predictors of how problematic or bothersome HFNS wereated [15]. Measures of cognitions and behaviours relating to HFNSave been developed for women, i.e. The Hot Flush Beliefs Scale [16]nd Hot Flush Behaviour Scales [17]. Changes in these HFNS beliefsnd behaviours were found to be the main mediators of improve-ent in HFNS in two clinical trials of CBT for women [18,19]. We

lan to test this cognitive model, as well as develop and evaluate CBT intervention to help men to manage HFNS while receivingDT treatment for PCa [20]. However, the first step is to developeasures of HFNS beliefs and behavioural reactions for men withFNS, comparable to those that have been developed for women

16,17].Little research has been carried out on appraisals and reactions

o HFNS in men with PCa, but one qualitative study of men havingDT [3] found that men reported a lack of control over their HFNSnd there was reluctance to disclose the type of symptoms thathey experienced to others. In a qualitative study aimed to specif-cally examine cognitions and behaviours relating to HFNS in menndergoing ADT for PCa [21], five main cognitive appraisals relatingo HFNS were identified: changes in oneself, impact on masculinity,mbarrassment/social-evaluative concerns, perceived control andcceptance/adjustment.

We aimed to build on these findings and devise a psychometri-ally sound, self-report questionnaire measure that might be usedo increase understanding of the factors that influence the experi-nce and impact of HFNS in men. This paper presents:

(i) pilot work to develop the Hot Flush Beliefs and Behaviour Scalein Men (HFBBS-Men), and

ii) initial data on its reliability, validity and factor structure.

We include participants from UK and Australian sites since weim to take the CBT interventions forward in these centres. Thistudy was funded by the Prostate Cancer Charity and NHS Researchthics Committee approval granted (South East London 2 REC, ref:1/LO/1114) and the Uniting Care Human Research Ethics Commit-ee (Brisbane, Australia).

. Pilot work

Potential questionnaire items to measure HFNS beliefs andehavioural reactions were derived from the qualitative studyescribed above [21], which was carried out for this purpose. Welso considered items from the scales that exist for the measure-ent of HFNS beliefs and behaviours for women, i.e. from the Hot


lush Beliefs Scale [16] and the Hot Flush Behaviour Scale [17]. Sub-cales of these scales for women included: beliefs about the socialnd interpersonal consequences of experiencing HFNS (e.g. ‘every-ne’s looking at me’), beliefs about coping and control (e.g. ‘there’s

PRESSs xxx (2014) xxx–xxx

nothing I can do to get rid of them’), and beliefs about night sweatsand sleep (e.g. ‘if I have a night sweat, I’ll never get back to sleep’).HFNS behavioural subscales included: avoidance (e.g. of social sit-uations and transport), positive behaviours (e.g. calm breathing,humour), and cooling behaviours (e.g. carrying water, fanning one’sself).

The initial version of the HFBBS-Men consisted of a total of 40items reflecting these domains; however, six items were removeddue to repetition of items, leaving a 34-item scale. Items wereboth positively and negatively worded to minimize response bias.Five men (recruited as described in the Methods section below)

with PCa and experiencing HFNS, were asked to read the question-naire and comment to the researcher while doing so about eachitem. They also provided specific feedback on a range of factors,including layout, coherence, ambiguity, rating scale preference. TheHFBS was subsequently modified to maximize conceptual clarity.Twelve items were dropped (considered less relevant, unclear, orrepetitious), and ambiguously worded items were appropriatelyrewritten, culminating in a 22-item measure that used a six-pointresponse scale: strongly disagree, moderately disagree, mildly dis-agree, mildly agree, moderately agree, and strongly agree (codedas 1–6). Participants were asked to:

“. . . tick the response that best describes the extent to whichyou agree or disagree with each statement based on your beliefs andreactions to your flushes and sweats in the past two weeks”. The HotFlush Beliefs and Behaviour Scale for Men (HFBBS-Men) includedboth beliefs and behaviours in one scale because, in our experi-ence of using the HFNS Beliefs and Behaviour Scales for women,social and control beliefs tend to correlate with positive copingbehaviours and avoidance; we also felt that a shorter single scalemight be easier to use to assess outcomes and mediators in clinicaltrials.

3. Factor structure, reliability and validity

3.1. Participants

We recruited 118 men from urology and oncology clinics in twocentres (London, UK and the Gold Coast, Australia) from large teach-ing hospitals, using the following inclusion criteria: PCa patientsaged above 18, English-speaking, who had a minimum of sevenHFNS weekly for at least 1 month. Patients, attending outpatientclinics, were recruited into the study by cancer nurses, radiologistsand oncologists; they were provided with study information andconsented in the waiting areas, or were contacted by the researchteam and after completing a telephone-screening interview, theywere provided with information and following consent, question-naires were completed.

3.2. Measures

Sociodemographic and clinical data included: age, marital status,cancer type (localized, locally advanced or metastatic), cancer treat-ments received (prostatectomy, radiotherapy and ADT) and timesince PCa diagnosis.

Hot Flush Beliefs and Behaviour Scale for Men (HFBBS-Men): 22items scale to measure HFNS beliefs and behaviours.HFNS: Self-reported weekly frequency and HFNS problem-ratingwere assessed using the Hot Flush Rating Scale (HFRS) [22]. HF/NSmeasures the total number of HF/NS reported in the past week.


HFNS problem-rating is the mean of three items (i.e. ‘To whatextent do you regard your flushes/sweats as a problem?’, ‘Howdistressed do you feel about your hot flushes?’, and ‘How much doyour hot flushes interfere with your daily routine?’) rated on a

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10-point Likert scales where a higher score indicates that thepatient views his HF/NS as highly bothersome and interfering withlife. The scale has good internal consistency in studies with women(Cronbach alpha = 0.9) and test–retest reliability (r = 0.8).Mood: Anxiety and depressed mood are measured using the 14-item Hospital Anxiety and Depression Scale (HADS) [23], which iswidely used in cancer populations [24].

.3. Analysis

.3.1. Factor analysis of the HFBSA total of 118 men completed the HFBBS-Men as well as the

easures described above. The sample size was considered ade-uate for conducting a factor analysis [25]. After a preliminary itemnalysis to discard any items, which might show limited variability,xploratory factor analysis was conducted to examine relationshipsnd constructs measured by the HFBBS items, as well as refine andeduce the number of related items to a conceptually clear scale.rincipal components analysis was used in the identification of itemlusters and factor loadings generated using both orthogonal andblique rotations to determine the most coherent and interpretableolution.

Reliability of subscales was examined using Cronbach alphaoefficients. Concurrent criterion validity of the HFBBS-Men wasnvestigated by correlating the HFBBS scores with relevant meas-res of mood (HADS) and HFNS frequency and problem-rating,s well as age, time since diagnosis and cancer type (localized,ocally advanced and metastatic). It was hypothesized that men

ho endorsed anxiety and depressed mood (HADS) might expressore negative beliefs on the HFBS. It was hypothesized that menith more negative beliefs on the HFBBS would endorse higherroblem ratings as measured by the Hot Flush Rating Scale. Analy-es were carried out using SPSS 18.0 for Windows.

. Results

.1. Characteristics of study participants

One hundred and eighteen participants, aged 69.25 (SD = 7.56)ears (range 49–85 years), were recruited from urban centres inhe UK (n = 70) and Australia (n = 48). The majority were married oriving with a partner (98) 83.1%, with fewer widowed (3) 2.5%, sep-rated/divorced 9 (7.6%) or never married (8) 6.8%. Cancer typesncluded: localized (43) 36.4%; locally advanced (49) 41.5% and

etastatic (26) 22.0%. Cancer treatments included surgery (22)8.60% and radiotherapy (78) 66.10%; while the majority (103,7.28%) were having, or had recently had, ADT. Average time sinceCa diagnosis was 21.13 (SD = 23.67), range 3–192, months; theajority (86%) were within 3 years of diagnosis. Scores on theADS were Anxiety Mean 4.61, SD = 3.57 and Depression Mean.99, SD = 3.36, and those scoring above the clinical cut-off points


≥8) were broadly similar to rates reported for men with PCa [26].FNS frequency and problem-rating scores are shown in Table 1.

able 1ot flush measures of frequency, severity and problem-rating (n = 118), means (SD).

Mean (SD) Range

Hot flush weekly frequency 32.37 (28.00) 7–210Night sweat weekly frequency 13.58 (12.65) 10–70

Total HFNS Frequency 45.94 (35.96) 7–280HFNS Problem-rating 4.08 (2.28) 1–10

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4.2. Factor analysis

A total of 22 items were considered; however, one item, ‘otherpeople manage their hot flushes better than I do’, was omitted atthis stage because there was a lot of missing data (14 men leftthis item blank) specifically for this item. Kaiser and Rice’s [27]Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was0.75, and Bartlett’s test of sphericity was significant ([�2] = 858.74,p < 0.0001), thus justifying factor analysis with these data [28].The HFBS responses were analyzed using principal componentsanalysis with Varimax rotation to determine the existence of inde-pendent factors [29]. Although an initial seven factor solution wasidentified, several items had low factor loading scores. The screeplot demonstrated a break in the slope between factors three andfour [30]. The analysis was therefore repeated and a three-factorsolution was selected, on the basis of (i) eigenvalues >1.0, (ii)scrutiny of the scree test and (iii) parallel analysis, which accountedfor 44.72% of the variance (range of eigenvalues 1.64–5.30). The ini-tial number of factors and the break in the scree slope was similarfor both UK and Australian subgroups. Three distinct dimensionswere obtained based on item content, and were well marked byat least three items each (Table 2). The criterion for inclusion in afactor was set at 0.50, in line with standard recommendations witha sample size of 100 [31].

Factor one accounted for 25.26% of the variance, and consistedof ten items, such as ‘When I have a hot flush, other people will beable to tell that I am unwell’, ‘Having a hot flush makes me feel lessmasculine’ and ‘When I have night sweats I won’t be able to get backto sleep’ reflecting negative beliefs and behaviours relating to HFNSin social contexts and at night, was entitled HFNS Social/Sleep. Fac-tor two accounted for 11.62% of the variance, and consisted of fouritems, such as ‘When I have hot flushes or night sweats I try toaccept them’, ‘When I have a hot flush, I try to be calm and relaxed’and ‘At least hot flushes mean that my cancer is being treated’ wasentitled Calm/Acceptance. Factor three accounted for 7.84% of thevariance and was named Humour/Openness, with three items suchas, ‘I use humour to deal with hot flushes’ and ‘I deal with my hotflushes by being open and talking about them with other people’.Four items (items 12, 14, 19 and 20, in Table 2), that either loadedon at least two factors or did not load highly on any factor, wereremoved.

A total of 17 items were retained in the HFBBS-Men, with threesubscales based on the factor analysis. The final questionnaire isshown in Appendix 1. The responses to the three subscales werenormally distributed. Higher scores on subscale 1 indicate morenegative beliefs and behaviours, while higher scores on subscales 2and 3 represent neutral or positive beliefs and behaviours. Table 3shows the distribution of responses and means (SD) for the HFBBS-Men subscales. Scoring of the 17-item HFBBS-Men is as follows,with each subscale score being between 1 and 6 and numberingreferring to the items of the scale in Appendix 1.

1. HFNS Social/Sleep (1 + 2 + 3 + 5 + 6 + 7 + 8 + 9 + 11 + 16)/102. Calm/Acceptance (4 + 10 + 12 + 15)/43. Openness/Humour (13 + 14 + 17)/3.

4.3. Reliability and validity

Internal consistency was assessed for each separate subscaleand Cronbach coefficient alphas are shown in Table 3. These find-ings indicate that all subscales have reasonable reliability. Thosewith fewer items had lower reliability as might be expected but


were retained because of their conceptual relevance. Pearson corre-lations between the means of the subscales of the HFBS are reportedin Table 4. The subscales were relatively independent, however,there was a small but significant negative association between

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Table 2HFBBS-Men items and factor loadings.Q9

Factors

1 2 3

1. When I have night sweats it is harder to cope the next day. 0.707 0.044 0.1322. I should not have to put up with hot flushes I shouldn’t have them. 0.592 −0.048 0.0023. When I have hot flushes I worry about what other people will think of me 0.638 0.162 0.0074. At least hot flushes mean that my cancer is being treated −0.003 0.631 −0.1065. Having a hot flush makes me feel less masculine 0.679 0.137 −0.2016. I find my night sweats troublesome to manage 0.732 −0.219 0.0027. When I have a hot flush, I am embarrassed 0.753 0.110 −0.0508. When I have a hot flush, other people will be able to tell that I am unwell 0.661 0.072 −0.0759. When I have night sweats I won’t be able to get back to sleep 0.714 −0.265 0.02910. When I have hot flushes or night sweats I try to accept them 0.003 0.513 −0.40911. Night sweats and disrupted sleep affect my general health 0.718 −0.102 0.06412. I don’t have any control over my hot flushes 0.297 −0.093 0.20313. When I have a hot flush, I try to be calm and relaxed .114 .577 −0.13414. I don’t go out as much now because of hot flushes 0.537 0.412 −0.10915. I use humour to deal with hot flushes 0.013 −0.048 0.62016. I take action to cool down (cold drinks, take off layers) when I have a flush 0.038 −0.410 0.59317. When I have hot flushes, I carry on and ignore them −0.098 0.599 0.12618. I have to leave or avoid some social situations because of hot flushes 0.637 0.216 0.08819. I don’t talk about hot flushes and night sweats because people wouldn’t understand 0.323 0.051 0.38620. I carry things with me (cold drinks, tissues) in case I have a hot flush 0.096 0.527 0.55621. I deal with my hot flushes by being open and talking about them with other people −0.260 −0.062 0.594

Extraction Method: Principal Component Analysis.Rotation Method: Varimax with Kaiser Normalization.

Table 3Hot Flush Beliefs and Behaviour Scale-Men subscales: Means (SD), range and internal reliability (Cronbach alpha).

Mean SD Range Min–Max Cronbach alpha

HFNS Social/Sleep 3.09 1.11 4.80 1.00–5.80 0.83Calm/Acceptance 2.73 0.97 4.50 1.00–5.50 0.57Openness/Humour 3.84 1.23 5.00 1.00–6.00 0.57

Table 4HFBBS subscale inter-correlations and correlations between subscales and HFNS frequency, problem-rating and mood (HADS anxiety and depression).

HFNS Social/Sleep Calm/Accept Openness/Humour HFNS Frequ HFNS Prob-rating HADS Anxiety HADS Dep

HFNS Social/Sleep 0.02 −0.09 0.21* 0.56** 0.50** 0.44**

Calm/Accept −0.28* −0.23* −0.07 −0.05 0.01Openness/Humour −0.04 −0.03 0.05 −0.07

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* p < 0.05.** p < 0.01.

alm/Acceptance and Humour/Openness suggesting that these areuite different strategies.

In term of validity, as hypothesized there were significant asso-iations between negative beliefs about HFNS in social situationsnd at night (subscale 1) and higher frequency and problem rat-ng scores on the HFRS. As hypothesized, there were significantositive correlations between HADS anxiety and depressed moodnd subscale 1, reflecting negative beliefs and behaviours aboutF and NS. No other relationships between subscales and HFNS orADS measures were significant, apart from a negative associationetween more frequent HFNS and lower scores of Calm/Acceptancesubscale 2).

Age was not associated with the three subscales, nor was timeince prostate cancer diagnosis. However, in terms of cancer type,en who had locally advanced cancer had significantly higher

cores on subscale 2, (i.e. they were more likely to report beliefs andehaviours consistent with Calm/Acceptance), than men with diag-oses of localized or metastatic cancer (locally advanced M = 3.17,D = 0.81 vs. localized M = 2.47, SD = 0.99, t = 3.71, df = 89, p < 0.0001,


I 0.33–1.08; locally advanced M = 3.17, SD = 0.8 vs. metastatic = 2.27, SD = 0.85, t = 4.48, df = 72, p < 0.0001, CI 0.50–1.31). In addi-

ion, men with metastatic cancer (M = 4.41 SD = 1.17) were moreikely to use Humour/Openness (subscale 3) compared to men

with locally advanced cancer (M = 3.56 SD = 1.17), t = −2.96 df = 72p < 0.004 CI −0.85 to −1.42. No other associations were significant.

5. Discussion

In this study, we examined HFNS cognitive appraisals andbehavioural strategies used by men with PCa and devised a psycho-metrically sound measure to assess these beliefs and behaviours.Principal components analysis of initial HFBBS-Men items followedby an examination of eigenvalues >1 and the scree test indicateda three-factor solution. The content of these factors suggested thatthe HFBBS was measuring dimensions of beliefs and behavioursrelating to HFNS in social contexts and at night, calm/acceptance,and Humour/Openness. Internal consistency was high for subscale1, and moderate for subscales 2 and 3, which contained fewer items.

The main subscale 1 is similar to two main subscales for womenwith HFNS [16,17], in that it contains items that reflect embarrass-ment and concern about what other people might think when therespondent is having a flush, as well as appraisal of night sweats


being hard to manage and impacting on health, coping the nextday and getting back to sleep. The items differed from the women’sscales in the inclusion of two additional social items: ‘when I have ahot flush people will think that I am unwell’ and ‘having a hot flush

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akes me feel less masculine’, which might reflect social stigmassociated with ill health and concerns about threats to masculin-ty. Men with PCa are older, average age 69 years in this study,ompared to menopausal women who tend to be in their fifties,nd women with HFNS following breast cancer treatment tend toe in remission, while 64% of the current sample of PCa patientsere having cancer treatment, and 22% had been diagnosed withetastatic cancer. Their concern about their illness being exposed

o others by their HFNS might reflect difficulty in dealing withheir illness in general, possibly stigma about a cancer diagno-is or not knowing how to answer questions from other people21]. Concerns about masculinity are common amongst men withCa, for whom sexual problems and gynecomastia are treatmentide effects [3,32–34], and there is evidence suggesting that thiss particularly the case for younger men following radical prosta-ectomy [35]. For both the current sample and for women withFNS, embarrassment and concern about hot flushes in social situ-tions is associated with ‘having to leave or avoid social situationsecause of hot flushes’. As is the case for anxiety, overly negativer in some cases ‘catastrophic’ beliefs about the consequences ofFNS can lead to behavioural avoidance [17].

The second subscale (Calm/Acceptance) included cognitive andehavioural items, such as ‘when I have HFNS I try to accept them’,nd ‘when I have a hot flush I try to be calm and relaxed’, and ‘when

have hot flushes I carry on and ignore them’, as well as ‘at leastot flushes mean that my cancer is being treated’. These appearo be positive accepting appraisals and strategies, similar to a sub-cale of the women’s Hot Flush behaviour Scale [17], apart fromhe additional meaning of HFNS signifying that a treatment is hav-ng an impact. In contrast the third subscale reflects more activeehavioural strategies, such as use of humour, taking active stepso cool down and talking to people openly about HFNS. Humouras often reported by men in our pilot work and in the qualita-

ive study [21] in order to deal with potentially distressing HFNSnd health problems, as well as interpersonal situations. These twoubscales were negatively correlated suggesting that they tap intoifferent types of reactions.

Correlational analyses demonstrated relationships in thexpected directions between subscale 1 of the HFBBS-Men andeasures of frequency and problem-rating of HFNS and mood.

hese results are consistent with research on women with HFNS,howing that anxiety and depressed mood are associated with neg-tive beliefs about hot flushes in social situations and about nightweats and sleep, which also predict HFNS problem-rating [15].hese findings suggest that the cognitive model of HFNS [14] maye applicable to men, in that that the experience of HFNS might acti-ate cognitive, behavioural and affective systems, and that men’seliefs and behaviours may have a role in maintaining or exacerbat-

ng HFNS. However, the direction of causality cannot be concludedrom this cross-sectional study.

Subscales 2 and 3 reflected beliefs and behavioural strategieshat were not associated with mood or HFNS problem-rating. How-ver, an attitude of Calm/Acceptance was less likely to be presenthen HFNS were more frequent. Further research is needed tonderstand the impact of Calm/Acceptance and Humour/Opennesss strategies, whether they are helpful or less helpful, and whetherhey might serve as moderators of psychological interventions,uch as CBT [18,19]. When we examined age and clinical factors,cores on the HFBBS-Men did not vary with age or time since diag-osis; however there were differences in cognitive appraisals ofFNS and behavioural reactions depending on cancer type or stage.alm/Acceptance was more likely to be adopted by men with locally


dvanced cancer than by those with localized or metastatic cancer.his subscale includes an item ‘at least hot flushes mean that myancer is being treated’, so having HFNS in the context of activereatment might render them more acceptable if they signify that


treatment is working. Interestingly, men with metastatic cancerwere more likely to use humour and openness than men with local-ized or locally advanced cancer. Although the HFNS beliefs were notassociated with time since diagnosis, men with metastatic cancerare likely to be dealing and adapting to a more complex processof symptoms and bodily changes [35] which could render HFNS asrelatively less troublesome. Using humour and openness can be ahelpful strategy to maintain well being and access social support[36].

Overall, the results suggest that the main set of beliefs andbehaviours for men that might have more theoretical and clinicalrelevance are likely to be those measured by subscale1, comprisingnegative beliefs about HFNS, which also have high internal reli-ability and associations with HFNS measures. A particular strengthof the HFBBS-Men is its high content and face validity; specifiedbeliefs and behaviours were generated from a variety of sourcesenabling it to be firmly grounded in men’s experiences. The HFBBS-Men was validated on samples that reflected the population forwhom the measure was intended. The participants were typical ofmen with prostate cancer and HFNS in the UK and Australian cen-tres sampled, including men with localized, locally advanced, andmetastatic cancer. Cancer treatments received included surgeryand radiotherapy and the majority were having ADT; all men hadHFNS and we can assume that for those not currently having ADTthat their HFNS were caused by prior surgery or ADT, given thatHFNS can continue even after treatments have stopped [2,6]. TheHFNS scores reflected a range of severity as measured by frequencyand problem-rating of HFNS.

The percentages of men scoring within the clinical range fordepression and anxiety (HADS) were 15% and 20%, respectively,which are similar to those reported in a recent meta-analysis ofprevalence of anxiety and depression (13/27 studies reported HADSdata) in men with PCa [26] and to an Australian sample of menwith PCa [37], where they are four to five times higher than thenational average [38]. Receiving a diagnosis of PCa is often stressful[40], and, while depression tends to peak within the first 3 months,it can fluctuate across the 3 years following diagnosis [40]. In asurvey of the supportive care needs of men living with PCa, theareas of greatest need were psychological distress, sexuality relatedissues and urinary tract symptoms [34]; the results of this studysuggest strong associations between depressed mood, anxiety andnegative HFNS beliefs and behaviours, factors which can impacton the experience of HFNS, which are one of the most commontreatment side effects.

Further research is needed to replicate these findings, withlarger, socially and ethnically diverse samples; confirmatory fac-tor analysis might be applied to test specific hypotheses about therelationship of beliefs and behaviours to the experience of HFNS.

6. Conclusions

The HFBBS-Men was developed to assess men’s cognitiveappraisals (beliefs) of and behaviours to their HFNS. Preliminaryanalyses indicate that this reliable and valid measure could con-tribute to an increased understanding of their experience of HFNS,help delineate reasons for individual differences in response tothese symptoms, and both inform and evaluate psychological inter-ventions to alleviate HFNS.

Contributors


MSH designed the study, carried out the analysis and wrote thepaper; CFS contributed to the analysis and final draft, ES and OYconducted the pilot study and collected and coded data, VB andDRH collected and coded data, and contributed to the final draft.

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ompeting interest

The authors have no conflicts of interest

unding

This study was funded by the Prostate Cancer Charity.

thics

NHS Research Ethics Committee approval granted (South Eastondon 2 REC, ref: 11/LO/1114) and the Uniting Care Humanesearch Ethics Committee (Brisbane, Australia).

ncited reference

[39].

ppendix 1. HFNS Beliefs and Behaviour Scale for MenHFBBS-Men)

This questionnaire lists beliefs about hot flushes and nightweats. Please tick the response that best describes how much yougree or disagree with each statement based on your beliefs andeactions to your flushes and sweats in the past 2 weeks. There areo right or wrong answers.

Stronglydisagree

Moderatelydisagree

Mildlydisagree

Mildlyagree

Moderatelyagree

Stronglyagree

1. When I have nightsweats it is harder to copethe next day.2. I should not have to putup with hot flushes Ishouldn’t have them.3. When I have hot flushesI worry about what otherpeople will think of me4. At least hot flushesmean that my cancer isbeing treated5. Having a hot flushmakes me feel lessmasculine6. I find my night sweatstroublesome to manage7. When I have a hot flush,I am embarrassed8. When I have a hot flush,other people will be ableto tell that I am unwell9. When I have nightsweats I won’t be able toget back to sleep10. When I have hotflushes or night sweats Itry to accept them11. Night sweats anddisrupted sleep affect mygeneral health12. When I have a hotflush, I try to be calm andrelaxed13. I use humour to dealwith hot flushes14. I take action to cooldown (cold drinks, takeoff layers) when I have aflush15. When I have hotflushes, I carry on andignore them16. I have to leave or avoidsome social situations


because of hot flushes17. I deal with my hotflushes by being open andtalking about them withother people

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PRESSs xxx (2014) xxx–xxx

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the hot flush beliefs and behaviour scale for men (hfbbs-men) undergoing treatment for prostate...

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