SpringerLink
Log in

Effects of the CALM intervention on resilience in Chinese patients with early breast cancer: a randomized trial

  • Research
  • Published:
Journal of Cancer Research and Clinical Oncology Aims and scope Submit manuscript

Abstract

Objective

Resilience is an important regulating factor for anxiety and depression in breast cancer. The Managing Cancer and Living Meaningfully (CALM) intervention has been confirmed to improve anxiety and depression in patients, but the role of resilience is still unclear. This study explores this issue.

Methods

In this study, a cohort of 124 patients diagnosed with breast cancer was recruited and randomly assigned to either the intervention group (IG) or the control group (CG). In addition, we enrolled a group of cancer-free women (regular control group) and assessed their resilience. All patients were evaluated using the Connor-Davidson Resilience Scale (CD-RISC), Hospital Anxiety and Depression Scale (HADS), Functional Assessment of Cancer Therapy (FACT-B) and Perceived Stress Scale (PSS) at different time points. The primary outcomes were resilience, quality of life, anxiety, depression, and perceived stress. A repeated measures ANOVA was used to compare the scores of the IG and CG groups. The relationship between resilience and quality of life was analyzed using Pearson's correlation test. The paired-sample t-test was used to compare the changes in each score at different time points.

Results

The intervention group showed significant differences in resilience, adamancy, optimism, tenacity, anxiety, depression, perceived stress and QOL scores before and after 6, 12, and 24 weeks (F = 17.411, F = 226.55, F = 29.096, F = 50.67, F = 82.662, F = 105.39, F = 62.66, F = 72.43, F = 34.561, respectively; P < 0.001). Compared to the control group, the intervention group demonstrated significant improvement in resilience and quality of life (t = -11.517, p < 0.001; t = − 4.929, p < 0.001), as well as a significant reduction in anxiety, depression, and perceived stress scores (t = 5.891, p < 0.001; t = 2.654, p < 0.001; t = 4.932, p < 0.001). In the intervention group, a significant positive correlation was observed between resilience in breast cancer survivors and quality of life (QOL) scores. (before CALM treatment: r = 0.3204, P = 0.0111; after 6 weeks: r = 0.3619, P = 0.0038; after 12 weeks: r = 0.3355, P = 0.0077; after 24 weeks: r = 0.2801, P = 0.0274).

Conclusions

A positive impact of the CALM intervention can be seen in improved resilience and reduced anxiety and depression, supporting its use as an effective psychological management tool and intervention strategy in the early stages of long-term breast cancer recovery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Germany)

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

Data availability

The datasets analyzed and generated in this study are not publicly available due to confidentiality agreements. However, interested parties may request access to the data from the corresponding author, subject to reasonable conditions.

Abbreviations

CALM:

Managing cancer and living meaningfully

IG:

Intervention group

CG:

Control group

BCS:

Breast cancer survivor

NCG:

Normal control group

VR:

Virtual reality

ER:

Estrogen receptor

PR:

Progesterone receptor

QOL:

Quality of life

References

  • Alizadeh AM, Heydari Z, Rahimi M, Bazgir B, Shirvani H, Alipour S, Heidarian Y, Khalighfard S, Isanejad A (2018) Oxytocin mediates the beneficial effects of the exercise training on breast cancer. Exp Physiol 103:222–235

    Article  CAS  PubMed  Google Scholar 

  • Bezjak A, Ng P, Taylor K, MacDonald K, Depetrillo AD (1997) A preliminary survey of oncologists’ perceptions of quality of life information. Psychooncology 6:107–113

    Article  CAS  PubMed  Google Scholar 

  • Bonanno GA, Diminich ED (2013) Annual research review: positive adjustment to adversity–trajectories of minimal-impact resilience and emergent resilience. J Child Psychol Psychiatry 54:378–401

    Article  PubMed  Google Scholar 

  • Bonanno GA, Westphal M, Mancini AD (2011) Resilience to loss and potential trauma. Annu Rev Clin Psychol 7:511–535

    Article  PubMed  Google Scholar 

  • Borgi M, Collacchi B, Ortona E, Cirulli F (2020) Stress and co** in women with breast cancer:unravelling the mechanisms to improve resilience. Neurosci Biobehav Rev 119:406–421

    Article  PubMed  Google Scholar 

  • Boškailo E, Franjić D, Jurić I, Kiseljaković E, Marijanović I, Babić D (2021) Resilience and quality of life of patients with breast cancer. Psychiatr Danub 33:572–579

    PubMed  Google Scholar 

  • Caruso R, Nanni MG, Rodin G, Hales S, Malfitano C, De Padova S, Bertelli T, Murri MB, Bovero A, Miniotti M, Leombruni P, Zerbinati L, Sabato S, Grassi L (2020) Effectiveness of a brief manualized intervention, managing cancer and living meaningfully (CALM), adapted to the Italian cancer care setting: study protocol for a single-blinded randomized controlled trial. Contemp Clin Trials Commun 20:100661

    Article  PubMed  PubMed Central  Google Scholar 

  • Casellas-Grau A, Font A, Vives J (2014) Positive psychology interventions in breast cancer. A Syst Rev Psycho-Oncol 23:9–19

    Article  Google Scholar 

  • Ding K, Zhang X, Zhao J, Zuo H, Bi Z, Cheng H (2020) Managing cancer and living meaningfully (CALM) intervention on chemotherapy-related cognitive impairment in breast cancer survivors. Integr Cancer Ther 19:1534735420938450

    Article  PubMed  PubMed Central  Google Scholar 

  • Dwek MR, Rixon L, Hurt C, Simon A, Newman S (2017) Is there a relationship between objectively measured cognitive changes in patients with solid tumours undergoing chemotherapy treatment and their health-related quality of life outcomes? A System Review Psycho-Oncology 26:1422–1432

    Article  Google Scholar 

  • Eicher M, Matzka M, Dubey C, White K (2015) Resilience in adult cancer care: an integrative literature review. Oncol Nurs Forum 42:E3-16

    Article  PubMed  Google Scholar 

  • El-Jawahri A, LeBlanc TW, Kavanaugh A, Webb JA, Jackson VA, Campbell TC, O’Connor N, Luger SM, Gafford E, Gustin J, Bhatnagar B, Walker AR, Fathi AT, Brunner AM, Hobbs GS, Nicholson S, Davis D, Addis H, Vaughn D, Horick N, Greer JA, Temel JS (2021) Effectiveness of integrated palliative and oncology care for patients with acute myeloid leukemia: a randomized clinical trial. JAMA Oncol 7:238–245

    Article  PubMed  Google Scholar 

  • Fan L, Strasser-Weippl K, Li JJ, St Louis J, Finkelstein DM, Yu KD, Chen WQ, Shao ZM, Goss PE (2014) Breast cancer in China. The Lancet Oncology 15:e279-89

    Article  PubMed  Google Scholar 

  • Feldman R (2020) What is resilience: an affiliative neuroscience approach. World Psy Off J World Psych Association (WPA) 19:132–150

    Google Scholar 

  • Finlay IG, Dunlop R (1994) Quality of life assessment in palliative care. Annals Oncology : Off J Europ Societ Med Oncol 5:13–18

    Article  CAS  Google Scholar 

  • Fortin J, Leblanc M, Elgbeili G, Cordova MJ, Marin MF, Brunet A (2021) The mental health impacts of receiving a breast cancer diagnosis: A meta-analysis. Br J Cancer 125:1582–1592

    Article  PubMed  PubMed Central  Google Scholar 

  • Fredrickson BL, Joiner T (2002) Positive emotions trigger upward spirals toward emotional well-being. Psychol Sci 13:172–175

    Article  PubMed  Google Scholar 

  • Freeman D, Lambe S, Kabir T, Petit A, Rosebrock L, Yu LM, Dudley R, Chapman K, Morrison A, O’Regan E, Aynsworth C, Jones J, Murphy E, Powling R, Galal U, Grabey J, Rovira A, Martin J, Hollis C, Clark DM, Waite F (2022) Automated virtual reality therapy to treat agoraphobic avoidance and distress in patients with psychosis (gameChange): a multicentre, parallel-group, single-blind, randomised, controlled trial in England with mediation and moderation analyses. The Lancet Psychiatry 9:375–388

    Article  PubMed  PubMed Central  Google Scholar 

  • A.K. Friedman, J.J. Walsh, B. Juarez, S.M. Ku, D. Chaudhury, J. Wang, X. Li, D.M. Dietz, N. Pan, V.F. Vialou, R.L. Neve, Z. Yue, and M.H. Han, (2014) Enhancing depression mechanisms in midbrain dopamine neurons achieves homeostatic resilience. Science (New York, N.Y.) 344, 313–9.

  • Geschwind N, Peeters F, Jacobs N, Delespaul P, Derom C, Thiery E, van Os J, Wichers M (2010) Meeting risk with resilience: high daily life reward experience preserves mental health. Acta Psychiatr Scand 122:129–138

    Article  CAS  PubMed  Google Scholar 

  • Han MH, Nestler EJ (2017) Neural Substrates of depression and resilience. Neurotherapeutics : J Am Societ Exp NeuroTherap 14:677–686

    Article  Google Scholar 

  • Henderson VP, Clemow L, Massion AO, Hurley TG, Druker S, Hébert JR (2012) The effects of mindfulness-based stress reduction on psychosocial outcomes and quality of life in early-stage breast cancer patients: a randomized trial. Breast Cancer Res Treat 131:99–109

    Article  PubMed  Google Scholar 

  • Isingrini E, Perret L, Rainer Q, Amilhon B, Guma E, Tanti A, Martin G, Robinson J, Moquin L, Marti F, Mechawar N, Williams S, Gratton A, Giros B (2016) Resilience to chronic stress is mediated by noradrenergic regulation of dopamine neurons. Nat Neurosci 19:560–563

    Article  CAS  PubMed  Google Scholar 

  • Labrague LJ, De Los Santos JAA (2020) COVID-19 anxiety among front-line nurses predictive role of organisational support personal resilience and social support. J Nurs Manag 28:1653–1661

    Article  PubMed  PubMed Central  Google Scholar 

  • Lee JH, Kim HY (2018) Symptom distress and co** in young korean breast cancer survivors: the mediating effects of social support and resilience. J Korean Acad Nurs 48:241–253

    Article  PubMed  Google Scholar 

  • Li L, Hou Y, Li L, Hou Y, Kang F, Wei X (2020) The mediating and moderating roles of resilience in the relationship between anxiety, depression, and post-traumatic growth among breast cancer patients based on structural equation modeling: An observational study. Medicine 99:e23273

    Article  PubMed  PubMed Central  Google Scholar 

  • Manigault AW, Kuhlman KR, Irwin MR, Cole SW, Ganz PA, Crespi CM, Bower JE (2021) Vulnerability to inflammation-related depressive symptoms: Moderation by stress in women with breast cancer. Brain Behav Immun 94:71–78

    Article  CAS  PubMed  Google Scholar 

  • Manigault AW, Kuhlman KR, Irwin MR, Cole SW, Ganz PA, Crespi CM, Bower JE (2022) Psychosocial resilience to inflammation-associated depression: a prospective study of breast-cancer survivors. Psychol Sci 33:1328–1339

    Article  PubMed  PubMed Central  Google Scholar 

  • Masten AS (2014) Global perspectives on resilience in children and youth. Child Dev 85:6–20

    Article  PubMed  Google Scholar 

  • Matthies LM, Taran FA, Keilmann L, Schneeweiss A, Simoes E, Hartkopf AD, Sokolov AN, Walter CB, Sickenberger N, Wallwiener S, Feisst M, Gass P, Lux MP, Schuetz F, Fasching PA, Sohn C, Brucker SY, Graf J, Wallwiener M (2019) An Electronic patient-reported outcome tool for the FACT-B (functional assessment of cancer therapy-breast) questionnaire for measuring the health-related quality of life in patients with breast cancer: reliability study. J Med Internet Res 21:e10004

    Article  PubMed  PubMed Central  Google Scholar 

  • Miceli J, Geller D, Tsung A, Hecht CL, Wang Y, Pathak R, Cheng H, Marsh W, Antoni M, Penedo F, Burke L, Ell K, Shen S, Steel J (2019) Illness perceptions and perceived stress in patients with advanced gastrointestinal cancer. Psychooncology 28:1513–1519

    Article  PubMed  PubMed Central  Google Scholar 

  • Mitchell AJ, Chan M, Bhatti H, Halton M, Grassi L, Johansen C, Meader N (2011) Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncol 12:160–174

    Article  PubMed  Google Scholar 

  • Nakamura ZM, Deal AM, Nyrop KA, Chen YT, Quillen LJ, Brenizer T, Muss HB (2021) Serial assessment of depression and anxiety by patients and providers in women receiving chemotherapy for early breast cancer. Oncologist 26:147–156

    Article  PubMed  Google Scholar 

  • Nissim R, Freeman E, Lo C, Zimmermann C, Gagliese L, Rydall A, Hales S, Rodin G (2012) Managing Cancer and Living Meaningfully (CALM): a qualitative study of a brief individual psychotherapy for individuals with advanced cancer. Palliat Med 26:713–721

    Article  PubMed  Google Scholar 

  • Oberstadt MCF, Esser P, Classen J, Mehnert A (2018) Alleviation of psychological distress and the improvement of quality of life in patients with amyotrophic lateral sclerosis: adaptation of a short-term psychotherapeutic intervention. Front Neurol 9:231

    Article  PubMed  PubMed Central  Google Scholar 

  • Pang L, Bi Z, **g Y, Yin X, Zhang X, Yao S, Zhao J, Cheng H (2021) Changes in cytokine levels in breast cancer patients with CRCI before or after CALM intervention. Am J Cancer Res 11:5415–5427

    CAS  PubMed  PubMed Central  Google Scholar 

  • Park CL, Edmondson D, Fenster JR, Blank TO (2008) Meaning making and psychological adjustment following cancer: the mediating roles of growth, life meaning, and restored just-world beliefs. J Consult Clin Psychol 76:863–875

    Article  PubMed  Google Scholar 

  • Park W, Kim J, Kim M (2021) Efficacy of virtual reality therapy in ideomotor apraxia rehabilitation: A case report. Medicine 100:e26657

    Article  PubMed  PubMed Central  Google Scholar 

  • Perez-Tejada J, Labaka A, Vegas O, Larraioz A, Pescador A, Arregi A (2021) Anxiety and depression after breast cancer: The predictive role of monoamine levels. Off J Europ Oncol Nurs Soc 52:101953

    Article  Google Scholar 

  • Perry S, Kowalski TL, Chang CH (2007) Quality of life assessment in women with breast cancer: benefits, acceptability and utilization. Health Qual Life Outcomes 5:24

    Article  PubMed  PubMed Central  Google Scholar 

  • Reinelt E, Aldinger M, Stopsack M, Schwahn C, John U, Baumeister SE, Grabe HJ, Barnow S (2014) High social support buffers the effects of 5-HTTLPR genotypes within social anxiety disorder. Eur Arch Psychiatry Clin Neurosci 264:433–439

    Article  PubMed  Google Scholar 

  • Reynolds LM, Cavadino A, Chin S, Little Z, Akroyd A, Tennant G, Dobson R, Broom R, Gautier A (2022) The benefits and acceptability of virtual reality interventions for women with metastatic breast cancer in their homes; a pilot randomised trial. BMC Cancer 22:360

    Article  PubMed  PubMed Central  Google Scholar 

  • Ristevska-Dimitrovska G, Filov I, Rajchanovska D, Stefanovski P, Dejanova B (2015) Resilience and quality of life in breast cancer patients. Open Acc Macedonian J Med Sci 3:727–731

    Article  Google Scholar 

  • Rodin G, Lo C, Rydall A, Shnall J, Malfitano C, Chiu A, Panday T, Watt S, An E, Nissim R, Li M, Zimmermann C, Hales S (2018) Managing cancer and living meaningfully (CALM): A randomized controlled trial of a psychological intervention for patients with advanced cancer. Off J Am Soc Clin Oncol 36:2422–2432

    Article  Google Scholar 

  • Rodríguez Del Águila M, González-Ramírez A (2014) Sample Size Calculation. Allergologia et Immunopathologia 42:485–492

    Article  PubMed  Google Scholar 

  • Rosenberg SM, Dominici LS, Gelber S, Poorvu PD, Ruddy KJ, Wong JS, Tamimi RM, Schapira L, Come S, Peppercorn JM, Borges VF, Partridge AH (2020) Association of Breast cancer surgery with quality of life and psychosocial well-being in young breast cancer survivors. JAMA Surg 155:1035–1042

    Article  PubMed  Google Scholar 

  • Schulze TG, Akula N, Breuer R, Steele J, Nalls MA, Singleton AB, Degenhardt FA, Nöthen MM, Cichon S, Rietschel M, McMahon FJ (2014) Molecular genetic overlap in bipolar disorder, schizophrenia, and major depressive disorder. The World J Biol Psy : Off J World Federation Societ Biol Psy 15:200–208

    Article  Google Scholar 

  • Schwab R, Droste A, Stewen K, Elger T, Theis S, Heimes AS, Peters K, Schmidt M, Brenner W, Hasenburg A (2022) Resilience as a source of easement to health-related Worries in women at increased risk for breast or ovarian cancer during the COVID-19 pandemic. Int J Gen Med 15:7039–7052

    Article  PubMed  PubMed Central  Google Scholar 

  • Soqia J, Al-Shafie M, Agha LY, Alameer MB, Alhomsi D, Saadoun R, Saifo M (2022) Depression, anxiety and related factors among Syrian breast cancer patients: a cross-sectional study. BMC Psychiatry 22:796

    Article  PubMed  PubMed Central  Google Scholar 

  • S.M. Southwick, and D.S. Charney, The science of resilience: implications for the prevention and treatment of depression. Science (New York, NY) 338 (2012) 79–82.

  • Sung H, Ferlay J, Siegel RL, 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 Cancer J Clin 71:209–249

    Article  PubMed  Google Scholar 

  • Tian J, Hong JS (2014) Assessment of the relationship between resilience and quality of life in patients with digestive cancer. World J Gastroenterol 20:18439–18444

    Article  PubMed  PubMed Central  Google Scholar 

  • Victoria Cerezo M, Ortiz-Tallo M, Cardenal V, De La Torre-Luque A (2014) Positive psychology group intervention for breast cancer patients: a randomised trial. Psy Report 115:44–64

    Article  CAS  Google Scholar 

  • Wu L, Tan Y, Liu Y (2017) Factor structure and psychometric evaluation of the connor-davidson resilience scale in a new employee population of China. BMC Psychiatry 17:49

    Article  PubMed  PubMed Central  Google Scholar 

  • Ye ZJ, Qiu HZ, Liang MZ, Liu ML, Li PF, Chen P, Sun Z, Yu YL, Wang SN, Zhang Z, Liao KL, Peng CF, Huang H, Hu GY, Zhu YF, Zeng Z, Hu Q, Zhao JJ (2017) Effect of a mentor-based, supportive-expressive program, be resilient to breast cancer, on survival in metastatic breast cancer: a randomised, controlled intervention trial. Br J Cancer 117:1486–1494

    Article  PubMed  PubMed Central  Google Scholar 

  • Yeung AWK, Tosevska A, Klager E, Eibensteiner F, Laxar D, Stoyanov J, Glisic M, Zeiner S, Kulnik ST, Crutzen R, Kimberger O, Kletecka-Pulker M, Atanasov AG, Willschke H (2021) Virtual and augmented reality applications in medicine: analysis of the scientific literature. J Med Internet Res 23:e25499

    Article  PubMed  PubMed Central  Google Scholar 

  • Zhang H, Zhao Q, Cao P, Ren G (2017) Resilience and quality of life: exploring the mediator role of social support in patients with breast cancer. Med Sci Monit: Int Med J Exp Clin Res 23:5969–5979

    Article  Google Scholar 

  • Zhang X, Yao S, Wang M, Yin X, Bi Z, **g Y, Cheng H (2022) The impact of VR-CALM Intervention Based on VR on psychological distress and symptom management in breast cancer survivors. J Oncology 2022:1012813

    Google Scholar 

  • Zhou K, Li J, Li X (2019) Effects of cyclic adjustment training delivered via a mobile device on psychological resilience, depression, and anxiety in Chinese post-surgical breast cancer patients. Breast Cancer Res Treat 178:95–103

    Article  PubMed  Google Scholar 

  • Zhou Z, Li J, Wang H, Luan Z, Du S, Wu N, Chen Y, Peng X (2023) Experience of using a virtual reality rehabilitation management platform for breast cancer patients: a qualitative study. Off J Multinat Asso Support Care Cancer 31:307

    Article  Google Scholar 

Download references

Acknowledgements

This research was supported by the Postgraduate Innovation Research and Practice Program of Anhui Medical University (No. YJS20230086).

Author information

Author notes

  1. Shaochun Liu, Runze Huang and Anlong Li have contributed equally to this work.

Authors and Affiliations

  1. Department of Oncology, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, China

    Shaochun Liu, Runze Huang, Anlong Li, Sheng Yu, Senbang Yao, Jian Xu, Lingxue Tang, Wen Li, Chen Gan & Huaidong Cheng

  2. Shenzhen Clinical Medical School of Southern Medical University, Guangzhou, China

    Huaidong Cheng

  3. Department of Oncology, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China

    Huaidong Cheng

Authors
  1. Shaochun Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Runze Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Anlong Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sheng Yu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Senbang Yao
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jian Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Lingxue Tang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Wen Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Chen Gan
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Huaidong Cheng
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Shaochun Liu, Runze Huang, and Anlong Li contributed equally to this work and shared the first authorship. They were involved in the study's conceptualization, data collection, analysis, interpretation, and manuscript preparation. Sheng Yu, Senbang Yao, Jian Xu, Lingxue Tang, and Wen Li participated in the data collection, research, and interpretation. They also contributed to the critical revision of the manuscript for important intellectual content. Chen Gan provided valuable guidance throughout the study, including the study design, interpretation of results, and necessary manuscript modifications. The corresponding author, Huaidong Cheng, supervised the entire research process, ensured the integrity of the work, and was the primary contact for correspondence related to the manuscript.

Corresponding author

Correspondence to Huaidong Cheng.

Ethics declarations

Conflict of interest

All authors declare that they have no conflicts of interest in this study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Liu, S., Huang, R., Li, A. et al. Effects of the CALM intervention on resilience in Chinese patients with early breast cancer: a randomized trial. J Cancer Res Clin Oncol 149, 18005–18021 (2023). https://doi.org/10.1007/s00432-023-05498-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00432-023-05498-0

Keywords

Search

Navigation