An Evidence-Informed Interpretive Structural Modeling Framework of Factors Associated with Posttraumatic Growth in Patients with Gynecologic Malignancies

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Objective: The aim of this study was to identify factors influencing posttraumatic growth (PTG) in patients with gynecologic malignancies, construct an interpretive structural modeling (ISM) framework, and examine the logical relationships and hierarchical structure among these factors to provide targets for clinical intervention. Methods: The system searched eight databases, and through literature screening, data extraction, and quality assessment, relevant studies were included to extract PTG influencing factors and form an initial item pool. Fifteen experts in the field were invited to evaluate, screen, revise, and preliminarily categorize the item pool. The same group of experts was then invited again to make binary judgments on pairwise direct relationships among the factors, based on which an adjacency matrix was constructed. Using MATLAB software, Boolean operations generated a reachability matrix, and hierarchical decomposition identified the level positions and grouping categories of the factors. Finally, an ISM model was developed and verified by expert review. Results: A total of 32 studies (8 in English and 24 in Chinese) were included, and 42 influencing factors were extracted. After expert consultation and revision, 37 factors were refined. The ISM analysis identified 3 category groups (independent group, associated group, and dependent group) and 4 levels (objective foundation level, psychological intermediary level, social support level, and coping behavior level), forming a hierarchical system of "13 core category factors - 37 operational sub-factors". The objective foundation level (demographic factors, disease characteristics factors) was positioned as the fundamental underlying factor, belonging to the independent group, and may affect the second-level psychological intermediary level (psychological resources and traits, emotional state, cognitive processing) and the third-level social support level (family function, social support, spiritual support); the psychological intermediary level and the social support level belong to the associated group, and there is an interaction effect between them, which is interpreted as the mediating transformation link; the coping behavior level (coping methods, health behaviors) is at the top level, belonging to the dependent group, and is the most direct influencing factor of PTG. Conclusion: The influencing factors of PTG in patients with gynecological malignant tumors exhibit a four-level hierarchical structure: "objective foundation layer → psychological intermediary layer - social support layer → coping behavior layer". This framework integrates 32 research evidences and 15 expert consensuses, clarifying the driving-dependent relationships and action paths among various factors. In clinical practice, stratified intervention can be implemented at different levels: prioritize intervention at the coping behavior layer to quickly activate PTG, continuously strengthen psychological and social collaborative intervention to consolidate the effect, and precisely identify high-risk individuals in the objective foundation layer to achieve early warning, thereby providing theoretical references for formulating personalized and precise psychological and social support plans for patients with gynecological malignant tumors.

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