The Relationship between Social Constrains, Social Isolation, Family Environment, Self-Efficacy, and Depressive Symptoms among Breast Cancer Patients in China

doi:10.21203/rs.3.rs-2250009/v1

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Research Article

The Relationship between Social Constrains, Social Isolation, Family Environment, Self-Efficacy, and Depressive Symptoms among Breast Cancer Patients in China

https://doi.org/10.21203/rs.3.rs-2250009/v1

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published 28 Sep, 2023

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Background: For female breast cancer patients, the psychological status after surgery, especially the social and family psychological related factors, deserves more attention. This study analyzed the influence of social constrain, social support, social isolation, family conflict, family emotion expression on depression. At the same time, this study conducted the relationship between the variables and the mechanism of action.

Methods: 522 breast cancer patients finished questionnaires consisting of Self-Rating Depression Scale (SDS), General Self-Efficacy Scale (GSES), Multi-Dimensional Scale of Perceived Social Support (MSPSS), Social Constraints Scale-5(SCS-5), Family Environment Scale(FES), and Lubben Social Network Scale (LSNS-6). Multivariable Logical Regression was used to explore influencing factors. Pearson’s Correlation, Hierarchical Regression and Simple Slope Analysis were conducted to verify the role of self-efficacy.

Results: 71.6% of patients had depressive symptoms. Family contradiction (OR=10.086), social constrain (OR=2.522), social isolation (OR=2.507), and high blood glucose (OR=2.156) were risk factors of depressive symptoms. Family emotional expression (OR=0.480), family intimacy (OR=0.235), and self-efficacy (OR=0.246) were protective factors against depressive symptoms. The interactive items interpretation quantity was as follows: Contradiction*Self-efficacy (ΔR²=2.3%, P<0.001), Emotional expression*Self-efficacy (ΔR²=2.6%, P<0.001), Intimacy*Self-efficacy (ΔR²=1.0%, P=0.018), Social constrain*Self-efficacy (ΔR²=1.0%, P=0.008), Social networks*Self-efficacy (ΔR²=1.0%, P=0.010), Blood Glucose*Self-efficacy (ΔR²=0.6%, P=0.023). The influence of independent variables on depressive symptoms were gradually decreased in the low, mean and high groups of self-efficacy.

Conclusion: Postoperative Chinese breast cancer survivors reported higher depressive symptoms. Social, family, and physiological factors can affect depressive symptoms, in which self-factor played moderator roles.

Family Environment

Social Constrain

Social Isolation

Blood Glucose

Self-Efficacy

On the basis of the latest global cancer data revealed by the IARC in 2021, female breast cancer (BC) has been the largest cancer in the world[1]. BC is the malignant tumor with the highest incidence rate and mortality in women, and there were 380,293 new cases of Chinese female BC in 2020, accounting for 17.4% of the world, with an annual growth rate of 3%~4% in China[1-2]. According to the survival data released worldwide, the five-year over-all survival about female breast cancer survivors (BCSs) is 92%, and the 10-year relative survival rate is 61% (54%~67%)[3]. With the improvement of survival rate, the mental symptoms of patients should also be paid attention to[4]. BCSs have serious emotional disorders, among which depressive symptoms is the most common. The incidence of depression among BCSs is 25%~62%[5-8]. At the same time, although most patients were inconsistent with the diagnostic standard of depression, they were still depressed. The proportion of depressive symptoms of BCSs was as high as 66.1% [9].

Social constraint means any social environment in which trauma survivors feel unsupported, misread, or estranged from social networks when they search social support or attempt talking about trauma related experiences[10]. BCSs have to bear multiple physical, psychological and social burdens for a long time. In order to release the psychological pain caused by multiple burdens, most cancer patients may choose to talk to family and friends to seek psychological comfort or solutions. In this process, patients may feel social constraints. Previous study pointed out that compared with social support, social constraint is more connected to the psychological distress of cancer patients[11]. Social cognitive processing theory proposed that society environment affects individual cognitive processing and adaptation to cancer[12]. Social restraint environment is the cause of increasing pain and bad psychological adjustment[13]. Studies have shown that patients’ perception of constraints can lead to depressive symptoms and other emotions[14]. Social isolation means that individuals are in a state of shrinking social network, lack of contact and social interaction with others, and lack of satisfied and high-quality social relations[15]. The theory of social affective selectivity points out that individuals pay more attention to small social networks composed of family members and long-term friends. The existence of family isolation is prone to emotional vacancy, which induces depressive symptoms, friend isolation and lack of peer support from friends, which also has an adverse impact on mental health. Previous results showed that social isolation could predict depressive symptoms[16]. For patients, family is a complex functional system. A good family environment helps individuals maintain positive emotions. Harmonious family atmosphere, family respect and care for patients will make patients feel good, happy and less depressive symptoms[17]. In addition to social and family psychological factors, clinical physiological indicators also have an impact on depressive symptoms. Studies have shown that low blood glucose levels may cause depressive symptoms[18]. Another study also showed that higher triglyceride glucose index was related to a higher odd of depressive symptoms[19].

Self-efficacy is the subjective judgment and self-confidence of an individual in the face of a specific situation about whether he can successfully complete a certain behavior goal or activity task[20]. The result will directly affect a person’s behavior motivation. The theory of self-efficacy focuses on exploring the internal psychological process, emphasizes the moderating effect of self-factor in behavior, and advocates the combination of behavior and cognition [21]. It believes that human behavior must be explained through the interaction between environment, behavior and people. Studies on cancer patients have shown that self-efficacy played positive roles in improving depressive symptoms as well as other adverse feelings[22,23]. Previous studies have confirmed that self-efficacy can moderate the impact of social support on depressive symptoms[24,25]. However, few studies have confirmed that self-efficacy can moderate the effects of social constrain, social isolation and family environment on depressive symptoms. Improving self-efficacy is also an effective measure to control blood glucose[26]. According to above researches, our study supposed that self-efficacy could alleviate depressive symptoms. On the basis of literature findings and diverse cultural background, this research aimed to prove the next assumptions in Chinese female BCSs:

Hypothesis 1: Social constrain, social isolation, poor family environment and high blood glucose have negative effects on depressive symptoms.

Hypothesis 2: Self-efficacy plays a positive role in depressive symptoms.

Hypothesis 3: Self-efficacy can moderate the associations between social constrain, social isolation, poor family environment, and high blood glucose on depressive symptoms.

Study Design and Sample

We conducted a cross-sectional study from 2019 to 2021. Patients were from breast surgery. The inclusion criteria of this study were as follows: (1) Chinese female, age ≥ 18 years; (2) Pathological diagnosis of breast cancer at any stage of the disease; (3) All operations have been completed and radiotherapy or chemotherapy continues. The exclusion criteria were as follows: patients with mental problems or cognitive and intellectual disabilities before cancer diagnosis. Researchers and medical staff distributed questionnaires to patients, and the investigators received strict training. 564 patients were selected for the study. As the missing value exceeded 10%, 42 patients were excluded (mainly the items of SDS questionnaire). Finally, 522 breast cancer patients were included in the analysis, and the effective recovery rate was 92.5%.

General situation questionnaire

It contained eight demographic variables, seven clinical variables, and ten biochemical indexes. Age was divided into: “≤45”, “46–55” and “≥56”. Education level was divided into “Middle school or under”, “High or secondary school”, and “Undergraduate or above”. Monthly income (RMB: Yuan) consisted of “≤3000”, “3001–4000”, “4001–5000” and “≥5001”. Residence was divided into: “city” or “rural”. Exposure to secondhand smoke was categorized as “No”, “1-3 days/week”, “More than 3 days/week”, and “Almost every day”. And one question: Have you ever been abused in the past year (including emotional abuse, silence violence, domestic violence, and verbal violence). Cancer stage included “0-I”, “II” and “III+IV”. Mastectomy, chemotherapy, radiotherapy, current recurrence, and menopause were divided into “yes” or “no”. Clinical biochemical indexes contained Body Mass Index (BMI), Albumin (Alb), Cholesterol (TC), Blood glucose (GLU), Triglyceride (TG), Hemoglobin (HB), Low-density lipoprotein (LDL), and High-density lipoprotein (HDL).

Assessment of Depressive Symptoms

We adopted the Zung’s Self-Rating Depression Scale (SDS)[27]. SDS includes emotional and physical symptoms, a total of 20 items, 10 of which are negative experiences and 10 are positive experiences. Add the scores of all items to form a rough score, multiply by 1.25, and round to get the standard score of anxiety. In our study, the index score of 50 (initial score=41) was set as the critical point for clinically significant depression. Cronbach’s alpha coefficient was 0.769 in our research.

Assessment of Social Support

The Multi-Dimensional Scale of Perceived Social Support (MSPSS) was used[28]. The scale includes 12 items and is divided into three measurement indicators: family support, friend support and important others support. Add the scores of all items to get the total score. The higher the total score, the better the social support. In this study, a total score of 12-36 indicates low support; 37-60 stands for moderate support; 61-84 stands for high support rate. Cronbach’s alpha coefficient was 0.969 in this study.

Assessment of Self-Efficacy

We adopted the Chinese version of the General Self-Efficacy Scale (GSES)[29]. GSES is widely used among Chinese people. The scale includes 10 entries. The total score of the scale is between 10 and 40. The higher the average score, the higher the self-efficacy. In our study, 10-20 points meant low self-efficacy; 20-30 points meant medium self-efficacy; 30-40 points meant high self-efficacy. Cronbach’s alpha coefficient was 0.952 in this study.

Assessment of Social Isolation

We used the abbreviated version of the Lubben Social Network Scale (LSNS-6)[30]. LSNS-6 consists of a group of three questions for evaluating kinship and a group of comparable three questions for evaluating non kinship. The total score is a weighted sum of six items, ranging from 0 to 3. This person will answer all six LSNS-6 items with a 12 point LSNS-6 score. In contrast, if two people can participate in some of the six categories, but not all of them, then we will think that this person is at risk of social isolation. Cronbach’s alpha coefficient was 0.911 in our research.

Assessment of Social Constraints

We used the Social Constraints Scale-5(SCS-5) to measure the degree of social relationships and the constraints they faced when talking about trauma related thoughts and feelings with other people[31]. This scale concludes five questions according to the interviewees’ experience last week which are asked twice: one is about the ‘most important person’ in the respondents’ life at that time, and the other is about the ‘other people’ in the respondents’ life (e.g., “How often did you feel as though you had to keep your feelings about your disease because they made [important other/other people] uncomfortable?”). Higher scores indicating a greater degree of social constraints. In this study, the mean value of the scale was taken as the critical value. Cronbach’s alpha coefficient was 0.865 in this study.

Assessment of Family Environment

We used the Family Environment Scale (FES) to evaluate these characteristics of 10 different family environments, and the exploratory factor analysis can obtain the three factor model including family relationship, personal growth as well as system maintenance[32]. The answer is divided into “Yes” and “No”. This study selected family relationship factors, including intimacy, emotional expression and contradiction. Cronbach’s alpha coefficient were 0.701, 0.690, 0.807 respectively in this study.

Data Analysis

We used IBM SPSS Statistics 21.0 (IBM, Asia Analytics Shanghai) statistical software for analysis, and the two tailed P<0.05 was considered statistically significant. Before data analysis, the normal distribution of variables was tested by P-P diagram analysis and Kolmogorov Smirnov test. We used χ² Test to analyze the effect of independent variables on depression. The independent variable whose chi square P value was less than 0.10 is included in the multivariable logical regression. Nagelkerke-R² was the coefficient of determination. The Hosmer-Lemeshow test was used to test the goodness-of-fit of the model. P-value >0.05 indicated that the goodness of fit is sufficient. Pearson correlation analysis was used. Hierarchical regression analysis was used to verify the moderating effect of self-efficacy. If the interaction was statistically significant, we would perform a simple slope analysis to visualize the interaction terms. Centralize variables before regression analysis

Demographic and clinical characteristics on depression

Of the 522 BCSs, 374 (71.6%) patients had depression. The average score of depression was 55.89±6.73. The relationship between demographic characteristics, clinical variables, clinical biochemical indexes, and psychological characteristics and depression were shown in Table 1.

Urban patients had a relatively lower prevalence of depression compared with rural patients (P=0.037). The patients who have been abused in the past year (including emotional abuse, silence violence, domestic violence, and verbal violence) had a relatively higher prevalence of depression (P=0.035).

Patients with BMI≥24 had a relatively higher prevalence of depression than those with BMI<24(P<0.001). Patients with low Alb and HB reported higher prevalence of depression (P<0.001). Patients with high GLU reported higher prevalence of depression (P<0.001).

Patients with social isolation had higher depression (P<0.001). Patients with social constrain reported more severe depression (P<0.001). Patients who felt high PSS showed lower prevalence of depression(P<0.001). Patients without family intimacy and family emotional expression had more severe depression (P<0.001). And patients with family contradiction had higher depression (P<0.001). Patients who had low self-efficacy reported higher depression (P<0.001).

The results of multivariable logistic regression analysis

Multivariate logistic regression analysis showed the risk factors of depression. Table 2 reported the findings of adjusting potential confounding population factor model. Age, residence, and whether have been abused in the past year were entered into the adjusted model as control variables. The Nagelkerke-R² for this model was 0.513 and the Homer-Lemeshow tests proved the adequate fitness of this model (χ²=9.938, P=0.270). Family contradiction, social constrain, social isolation, and high GLU were risk factors of depression. Family intimacy, family emotional expression, and self-efficacy were protective factors of depression.

Correlations among continuous variables

Table 3 showed of depression was positively correlated with family contradiction, social constrain, and GLU, and was negatively correlated with family intimacy, family emotional expression, social networks, and self-efficacy. Self-efficacy was positively correlated with family intimacy, family emotional expression, social networks, and was negatively correlated with family contradiction, social constrain, and GLU.

Hierarchical regression analysis

Table 4 showed the moderating effect. The first step is to add control variables, the second part is to add independent variables and moderator variables, and the third step is to add interactive items. This table showed only the interaction items added in the last block. The moderator effect of self-efficacy in family factors on depressive symptoms: the Contradiction*Self-efficacy explained an extra 2.3% of the variance (P<0.001); the Intimacy*Self-efficacy explained an extra 1.0% of the variance (P=0.018); the Emotional expression*Self-efficacy explained an extra 2.6% of the variance (P<0.001). The moderator effect of self-efficacy in social factors on depressive symptoms: the Social constrain*Self-efficacy and the Social networks*Self-efficacy explained an extra 1.0% of the variance respectively (P=0.008, 0.010). And the GLU*Self-efficacy explained an extra 0.6% of the variance (P=0.023).

Simple slope analysis

Figure 1 showed that the associations between family contradiction, family intimacy, family emotional expression, social constrain, social networks, GLU and depression were gradually decreased in the low (-1SD below the mean), mean and high (+1SD above the mean) groups of self-efficacy.

Results suggested that 71.6% of BCSs reported depressive symptoms in our research, which was larger compared with most previous studies (25.0%-66.1%)[6-10]. However, the average score of depression was 55.89±6.73, which meat that most of the patients in the research were mild depressed. The high incidence may be due to the patient’s concern about the relationship between husband and wife, cancer recurrence or changes in their own morphology, which made them prone to depressive symptoms[33].

Effect of Family Environment on Depressive symptoms

The results showed that the incidence of depressive symptoms in patients with family conflict was higher than patients with family intimacy and family emotional expression. Previous studies have also confirmed the long-term relationship between family contradiction and the risk of depressive symptoms, in which verbal and psychological contradictions were more likely to cause depressive symptoms than physical contradiction[34]. Family intimacy was expressed by the mutual support, love and harmonious relationship among family members. During stress, patients tend to turn to close people for comfort and support. Therefore, it was considered that the response of lack of partner attention may undermine the sense of “safe harbor” of intimate relationship and lead to a decline in adaptability[35]. Chinese families generally suffer from “emotional expression embarrassment”, which stems from the implicit genes of Chinese traditional culture. Cancer patients avoid showing their thoughts or feelings to their partners. As time goes by, their inner feelings will be released nowhere, leading to loneliness, which might become a hazard factor of depressive symptoms [36]. Generally, depressive symptoms may be caused by emotional incompatibility between husband and wife, lack of high-level mutual understanding, too inclined or unequal family status, disharmonious sexual life between husband and wife, conflict between other family members and abuse in some special families[37].

Effect of Social Environment on Depressive symptoms

Patients who feel social constraints will show more depressive symptoms. Previous research showed that BCSs expressed more concerns about cancer, but had less opportunities to express their concerns to others, which indicated that social constraints of BCSs were widespread[38]. A Study of 60 female patients with a family history of BC founded that the higher the social constraints you feel, the more painful your psychology is[39]. Study also confirmed that patients’ social constraint was positively connected to depressive symptoms consistent with our result[40]. Although social constraints can occur in any relationship context, social constraints from intimate partners may be the most important[41]. Therefore, it was suggested that the patients’ spouses should listen patiently and respond positively when the patients express their concerns about the disease. In this study, patients who felt that their social networks were affected suffer from severe depression, which was in accordance with previous researches about the negative effects of social isolation on mental health, and emphasized the key role of subjective social isolation on depression[42]. As previous studies have shown, growing loneliness caused by social isolation may lead to depression[36]. If the patients’ interaction with family members and friends is an important source of stress, they may choose to voluntarily limit contact with them. The loss of social network may increase the subjective social isolation of the elderly, hence bring some potential harm to mental health.

Effect of Physiological Factors on Depressive symptoms

Patients with high GLU showed more depressive symptoms. Long term high GLU will cause certain effects on the nervous system in the body. When adrenaline was elevated, people would become excessively anxious and increased the burden on various organs, and requires long-term medication, diet control and strict self-control. Therefore, it would play a certain role in the mood of patients, especially depressive symptoms[43]. Lifestyle treatment as well as drug treatment should be matched together to achieve very good blood glucose control and alleviate depressive symptoms.

Moderating effect of self-efficacy

BCSs who felt more self-efficacy reported lighter depressive symptoms. In the face of possible danger, misfortune, disaster and other malignant situational conditions, self-efficacy determined the psychosomatic reaction processes such as individual stress state, anxiety response and the degree of depression[20]. Previous study showed that potentiate self-efficacy could assist medical staff achieve better functional outcomes, consisting of depression relief[44]. Therefore, maintaining a positive sense of self-efficacy was also very important in preventive medicine to promote physical health.

Our study also founded self-efficacy can attenuate the effects of social environment, family environment on depressive symptoms among Chinese BCSs. It showed that if BCSs feel social constraints, social isolation, family conflicts, poor family intimacy and difficulty in emotional expression, they may have depressive symptoms. If the patients’ self-efficacy is high, the impact of the above difficulties on depressive symptoms would be decreased under the buffer of self-efficacy. The result was concordant with our hypothesis. This may be patients with high self-efficacy tend to think about problems from a positive perspective and form positive expectations before solving problems, and when encountering problems, they will also view them with an optimistic attitude and less anxiety and depression[45]. Another reason may be that patients with a high sense of self-efficacy will not worry before dealing with environmental events and doubt their ability to deal with and control the environment. However people with low self-efficacy worry that the environment is full of danger, so they experience strong stress and anxiety arousal, and passively respond to the environment with various protective withdrawal behaviors or defensive behaviors[46]. The sense of self-efficacy realizes its main role through several intermediate processes. That is to say, it directly affects the individual’s function in the dynamic psychological process of carrying out this activity, and thus constitutes a near cause that determines human behavior[46]. In addition, self-efficacy can be involved in the relationship between stressors and immune system by influencing biochemical processes in vivo. When faced with the same stressors, patients who had a higher self-efficacy would not show an increase in the secretion level of these substances, thus ensuring the normal balance of the immune system; However, the lack of self-efficacy leaded to the obvious improvement of the biochemical level of these substances, which broke the normal balance of the immune system and destroys its immune function[46].

Our findings showed the depressive symptoms of BCSs were common in China. Family contradiction, social constrain, social isolation, and high GLU were proved to be hazard factors for depressive symptoms. Family intimacy, family emotional expression, and self-efficacy were identified as protective factors against depressive symptoms. At the same time, the study found self-efficacy can improve the effect of social constraints, social isolation, family conflicts, family intimacy, family emotional expression, GLU on depressive symptoms among Chinese BCSs.

Funding

This work was supported by National Natural Science Foundation of China [Grant Number: 71904204].

Conflict of interest

The authors declare that they have no conflicts of interest.

Availability of data and material

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Code availability

Not applicable.

Authors’ contributions

Hui Wu, MengYao Li and ZhiHui Gu contributed to the study conception and design. Data collection was performed by Li Liu and Yue Ban. Data analysis was performed by MengYao Li and ZhiHui Gu. The first draft of the manuscript was written by MengYao Li and ZhiHui Gu. All authors contributed to the study conception and design and commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of China Medical University. The procedures of this study were reviewed and approved. Written informed consent for the investigation was obtained from each participant. We protected personal privacy when handling personal data and kept personal records confidential.

Consent to participate

Written or verbal informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable

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Table 1 Comparison of different characteristics of BC patients (N=522)

Variables	n(%)	Depressive symptoms		χ²	P-value
Variables	n(%)	No, n	Yes, n	χ²	P-value
*Demographic characteristics*
Age				3.819	0.148
≤45	71(13.6)	25	46
46–55	153(29.3)	48	105
≥56	298(57.1)	75	223
Education level				3.497	0.174
Middle school or under	173(33.1)	48	125
High or secondary school	235(45.0)	60	175
Undergraduate or above	114(21.8)	40	74
Income (Yuan per Month)				4.077	0.253
≤3000	134(25.7)	41	93
3001-4000	263(50.4)	66	197
4001-5000	57(10.9)	16	41
≥5001	68(13.0)	25	43
Residence				4.337	0.037
Urban	402(77.0)	123	279
Rural	120(23.0)	25	95
Exposure to secondhand smoke				7.233	0.065
No	64(12.3)	27	37
1-3 days / week	31(5.9)	9	22
More than 3 days / week	103(19.7)	29	74
Almost every day	324(62.1)	83	241
Have been abused in the past year				4.435	0.035
Yes	278(53.3)	68	210
No	244(46.7)	80	164
*Clinical characteristics*
Cancer stage				2.716	0.257
0-I	151(28.9)	46	105
II	213(40.8)	65	148
III+IV	158(30.3)	37	121
Mastectomy				0.063	0.801
Yes	34(6.5)	9	25
No	488(93.5)	139	349
Chemotherapy				2.039	0.153
Yes	306(58.6)	94	212
No	216(41.4)	54	162
Radiotherapy				0.065	0.799
Yes	158(30.3)	46	112
No	364(69.7)	102	262
Current recurrence				0.001	0.971
Yes	71(13.6)	20	51
No	451(86.4)	128	323
Menopause				0.081	0.776
Yes	354(67.8)	99	255
No	168(32.2)	49	119
*Clinical biochemical indexes*
BMI				13.613	<0.001
<24	247(47.3)	89	158
≥24	274(52.7)	59	216
Alb				12.580	0.002
Low	65(12.5)	14	51
Moderate	440(84.3)	123	317
High	17(3.3)	11	6
TC				2.346	0.126
Moderate	168(32.2)	55	113
High	354(678)	93	261
GLU				41.622	<0.001
Moderate	308(59.0)	120	188
High	214(41.0)	28	186
HB				11.073	0.004
Low	64(12.3)	7	57
Moderate	438(83.9)	134	304
High	209(3.8)	7	13
TG				1.209	0.272
Moderate	114(21.8)	37	77
High	408(78.2)	111	297
HDL				0.394	0.821
Low	202(38.7)	60	142
Moderate	226(43.3)	61	165
High	94(18.0)	27	67
LDL				1.333	0.248
Moderate	333(63.8)	100	233
High	186(35.6)	47	139
*Psychological variables*
Social isolation				38.586	<0.001
Yes	217(41.6)	30	187
No	305(58.4)	118	187
Social constrain				22.344	<0.001
Unconstrained	326(62.5)	116	210
Constrained	196(37.5)	32	164
PSS				16.986	<0.001
Low	136(26.1)	23	113
Moderate	176(33.7)	47	129
High	210(40.2)	78	132
Family intimacy				33.153	<0.001
Yes	393(75.3)	137	256
No	129(24.7)	11	118
Family emotional expression				41.995	<0.001
Yes	128(24.5)	65	63
No	394(75.5)	83	311
Family contradiction				121.074	<0.001
Yes	287(55.0)	25	262
No	235(45.0)	123	112
Self-efficacy				43.023	<0.001
Low	188(36.0)	23	165
Moderate	283(54.2)	99	184
High	51(9.8)	26	25
Notes: BMI:Body Mass Index; Alb:Albumin; TC: Cholesterol; GLU: Blood glucose; HB: Hemoglobin; TG: Triglyceride; HDL:High-density lipoprotein; LDL: Low-density lipoprotein; PSS: perceived social support

Table 2 Multivariable logistic regression of factors affecting depressive symptoms

Factors	B	S.E.	Wald χ2	P	OR	95%CI
Family contradiction (Yes vs. No )	2.311	0.300	59.168	<0.001	10.086	5.597-18.175
Social constrain(Yes vs. No)	0.925	0.314	8.692	0.003	2.522	1.363-4.664
Social isolation (Yes vs. No)	0.919	0.292	9.876	0.002	2.507	1.413-4.446
GLU (High vs. Moderate)	0.768	0.287	7.161	0.007	2.156	1.228-3.786
Family emotional expression (Yes vs. No)	-0.733	0.290	6.410	0.011	0.480	0.272-0.847
Family intimacy (Yes vs. No)	-1.447	0.412	12.328	<0.001	0.235	0.105-0.528
Self-efficacy (Moderate vs. Low)	-1.232	0.323	14.502	<0.001	0.292	0.155-0.550
Self-efficacy (High vs. Low)	-1.401	0.490	8.165	0.004	0.246	0.094-0.644
PSS (Moderate vs. Low)	0.302	0.376	0.648	0.421	1.353	0.648-2.826
PSS (High vs. Low)	-0.748	0.407	3.377	0.066	0.473	0.213-1.051
Constant	1.262	0.580	4.725	0.030	3.531
Notes: GLU: Blood glucose; PSS: perceived social support; OR: odds ratio

Table 3 Correlations among study variables

Variables	Depressive symptoms		Self-efficacy
Variables	r	p	r	p
Family contradiction	0.559	<0.01	-0.322	<0.01
Family intimacy	-0.490	<0.01	0.237	<0.01
Family emotional expression	-0.456	<0.01	0.232	<0.01
Social constrain	0.384	<0.01	-0.061	0.167
Social networks	-0.481	<0.01	0.194	<0.01
GLU	0.546	<0.01	-0.236	<0.01
Self-efficacy	-0.388	<0.01	1	-

Table 4 The moderating effect of self-efficacy on depressive symptoms

Variables	Adjusted R²	ΔR²	Unstandardized Coefficients b	Standardized Coefficients B	P
Family factors
Contradiction*Self-efficacy	0.425	0.023	1.016	0.156	<0.001
Intimacy*Self-efficacy	0.365	0.010	-0.547	-0.091	0.018
Emotional expression*Self-efficacy	0.396	0.026	-0.926	-0.161	<0.001
Social factors
Social constrain*Self-efficacy	0.327	0.010	-0.575	-0.097	0.008
Social networks*Self-efficacy	0.386	0.010	-0.558	-0.090	0.010
Physiological factors
GLU*Self-efficacy	0.403	0.006	0.510	0.078	0.023
Notes: GLU: Blood glucose

No competing interests reported.

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The Relationship between Social Constrains, Social Isolation, Family Environment, Self-Efficacy, and Depressive Symptoms among Breast Cancer Patients in China

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