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Original article
Affect as a mediator between self-efficacy and quality of
life among Chinese cancer survivors in China
N.C.Y. YEUNG,
MPHIL,
Department of Psychology, University of Houston, Houston, TX, & Q. LU,
MD, PHD,
Department of Psychology, University of Houston, Houston, TX, USA
YEUNG N.C.Y. & LU Q. (2014) European Journal of Cancer Care 23, 149–155
Affect as a mediator between self-efficacy and quality of life among Chinese cancer survivors in China
Previous studies have shown that self-efficacy influences cancer survivors’ quality of life. As most of the
relevant findings are based on Caucasian cancer survivors, whether the same relationship holds among Asian
cancer patients and through what mechanism self-efficacy influences quality of life are unclear. This study
examined the association between self-efficacy and quality of life among Chinese cancer survivors, and
proposed affect (positive and negative) as a mediator between self-efficacy and quality of life. A sample of 238
Chinese cancer survivors (75% female, mean age = 55.7) were recruited from Beijing, China. Self-efficacy, affect
(positive and negative) and quality of life were measured in a questionnaire package. Self-efficacy was positively associated with quality of life and positive affect, and negatively associated with negative affect. Path
analyses revealed the direct effect from self-efficacy to quality of life and the indirect effects from self-efficacy
to quality of life through positive affect and negative affect. The beneficial role of self-efficacy in Chinese
cancer survivors’ quality of life and the mediating role of affect in explaining the relationship between
self-efficacy and quality of life are supported. Future interventions should include self-care and affect regulation skills training to enhance cancer survivors’ self-efficacy and positive affect, as this could help to improve
Chinese cancer survivors’ quality of life.
Keywords: self-efficacy, affect, quality of life, Chinese, cancer survivors.
INTRODUCTION
Self-efficacy, the extent of a person’s confidence in his or
her ability to execute a course of action, has been shown
to be associated with people’s adaptation to cancer (Lev
1997). Previous studies have shown that self-efficacy is
positively associated with physical and psychological
quality of life and inversely associated with distress
among different groups of cancer survivors (Hochhausen
Correspondence address: Qian Lu, Department of Psychology, 126 Heyne
Building, University of Houston, Houston, TX 77204-5022, USA (e-mail:
qlu3@uh.edu).
The authors declare no conflicts of interest with respect to authorship
and/or publication of this article. The authors received no financial support
for the research and/or authorship of this article.
Accepted 14 August 2013
DOI: 10.1111/ecc.12123
European Journal of Cancer Care, 2014, 23, 149–155
© 2013 John Wiley & Sons Ltd
et al. 2007; Howsepian & Merluzzi 2009; Mosher
et al. 2010). Because studies examining the relationship
between self-efficacy and quality of life were primarily
conducted among Western populations, whether the same
relationship holds among Asian cancer patients is unclear.
In Chinese culture, coping with illness is largely a
family affair (Liu et al. 2005). Emphasising filial piety,
caring for the sick is also regarded as a duty and obligation
to Chinese families. In the context of cancer adaptation,
the immediate family is often the source of primary
support. Chinese cancer survivors tend to rely on the
interpersonal resources from family members to meet
their practical and psychological needs. Qualitative
studies have found that family members of Chinese
cancer survivors actively participated in caregiving tasks,
information seeking and treatment decision-making
(Liu et al. 2005; Wong-Kim et al. 2005). Quantitative
studies have found that family support was positively
YEUNG & LU
associated with Chinese cancer patient’s well-being (Sun
& Stewart 2000; Chan et al. 2009). These suggest the critical role of family support in the well-being among Chinese
cancer patients. Given that Chinese cancer patients
are more likely to have readily available interpersonal
resources from their family members, it is also important to examine if patients’ intrapersonal resources (e.g.
perceived self-confidence in dealing with cancer-related
stressors) influence their well-being. There is a paucity
of studies examining the beneficial role of self-efficacy
on well-being among Chinese cancer survivors. Findings
could provide useful recommendations for planning the
interventions for this population.
In the literature, there is no conclusive evidence
about the beneficial role of self-efficacy on well-being
among Chinese cancer patients. One study in Hong Kong
showed that self-care self-efficacy was positively associated with all subscales of the Short-Form Health Survey
36 among Chinese patients receiving intestinal stoma
surgery (Wu et al. 2007). Similarly, a longitudinal study
in Hong Kong showed that higher general self-efficacy at
1 week after breast cancer surgery was associated with
lower psychological morbidity and higher social adjustment at 1-month follow-up (Lam & Fielding 2007).
However, this study also showed that self-efficacy was
positively associated with incongruence between patient’s
expected outcome and actual outcome of the surgery,
which in turn reduce psychological well-being and social
adjustment. With these empirical inconsistencies, the
first goal of this study was to clarify the associations
of self-efficacy and quality of life among Chinese cancer
survivors.
The second goal of our study is to understand the pathways linking self-efficacy and well-being. Several potential mediators (e.g. optimism, benefit finding, positive
social comparison) have been suggested to explain the
relationship between self-efficacy and well-being in previous studies (Schulz & Mohamed 2004; Karademas 2006;
Luszcynska et al. 2007). Johnston-Brooks et al. (2002)
found that self-care self-efficacy mediated the association
between self-efficacy and the physical outcome (HbA1c)
among adults with Type I diabetes. Kershaw et al. (2008)
found that hopelessness mediated the relationship
between self-efficacy at baseline and mental quality of life
at 8 months among 121 prostate cancer patients; while
negative appraisal mediated the relationship between selfefficacy and physical quality of life. These studies show
that self-efficacy may influence well-being through cognitive and behavioural mediators. However, remaining
unknown is whether affect can be a potential mediator
between self-efficacy and quality of life.
150
According to the Social Cognitive Theory, self-efficacy
helps to attain a desired outcome, which in turn affects
psychosocial functioning (Bandura 1977, 1997). It also
suggests that self-efficacy creates positive affective
states because it represents people’s confidence in using
the skills necessary to cope with stress and mobilising
resources to meet situational demands. People with
higher self-efficacy may experience a lower level of negative emotions in a threatening situation because they recognise their ability to overcome obstacles and focus on
opportunities (Bandura 1997). Empirical studies have also
shown the beneficial effect of positive affect and the detrimental effect of negative affect on longevity and health
outcomes among healthy and patient populations (Howell
et al. 2007; Xu & Roberts 2010; Diener & Chan 2011). The
Broaden-and-Build Theory (Fredrickson 2001) also proposes that positive affect and negative affect can function
as determinants of well-being, not only as the indicators of
well-being. It postulates that positive affect can broaden
people’s scopes of cognition and build resources for future
coping, which in turn can initiate upward spirals for better
well-being. In contrast, negative affect can narrow people’s thought-action repertoires and thus reduces personal
resources to cope with adversity, which in turn decreases
well-being (Fredrickson & Joiner 2002). All these suggest
that self-efficacy may influence well-being through affective pathways.
Although affect has not been directly tested as a mediator between self-efficacy and quality of life in the literature, several studies have shown the association between
affect and self-efficacy and the association between affect
and cancer-related quality of life. Higher self-care selfefficacy has been found to be associated with higher positive affect, lower depression and emotional distress, and
lower negative affect among cancer patients in Canada
(Cunningham et al. 1991), Japan (Hirai et al. 2002; Kohno
et al. 2010; Deno et al. 2012) and the USA (Campbell et al.
2004; Heitzmann et al. 2011). Quality of life has also been
found to be positively associated with positive affect, and
negatively associated with negative affect among different
groups of cancer patients (Kessler 2002; Bower et al. 2005).
One study in Israel also showed that self-efficacy influences quality of life by reducing perceived stress (Kreitler
et al. 2007). All of these findings imply that a mediating
relationship may exist between self-efficacy and quality of
life through affect. This study thus aimed to address and
clarify existing knowledge gaps by proposing affect as a
mediator to explain the association between self-efficacy
and quality of life. We hypothesised that self-efficacy
would be positively associated with quality of life, and
positive affect and negative affect would mediate the
© 2013 John Wiley & Sons Ltd
Quality of life among Chinese cancer survivors
versions of the scales were compared and discussed. The
translated scales were modified to reflect the intended
meanings of the items in the original English version.
Positive
affect
Quality of
life
Self-efficacy
Affect
Negative
affect
Figure 1. Hypothesised model.
relationship between self-efficacy and quality of life
(Fig. 1).
METHOD
Participants
The sample consisted of Chinese cancer survivors (75%
female) with a mean age of 55.7 (SD = 9.1, ranging from
33 to 75). Over 80% of participants were retired and 45%
received an associate degree or a college education. A vast
majority were married (90%). Over two-thirds (67%) of
the participants were diagnosed with either Stage I or
Stage II cancer. The most common types of cancer were
breast (51.9%), uterine, cervical and ovarian (11.6%), and
colorectal and intestinal (9.9%) with most of them
(73.5%) having survived for at least 2 years after diagnosis.
A majority of them had undergone surgery (95%), chemotherapy (81.1%) and Traditional Chinese Medicine treatment (82.4%).
Recruitment
Participants were recruited from cancer associations in
Beijing, China. Chinese cancer patients who were able to
read Chinese were eligible for this cross-sectional survey.
Prospective participants were introduced to the study.
Participants received an envelope with a questionnaire
packet distributed by the staff at the cancer associations.
Participants completed the questionnaires at home and
then returned them in a sealed envelope. The questionnaires took approximately 40 min to complete. A total
of 238 out of the 280 distributed questionnaires were
returned, yielding a response rate of 85%. Relevant Institution Review Board approval was obtained.
Measurements
All scales were translated from English to Chinese and
back-translated by two bilingual psychology graduate
students. The forward-translated and back-translated
© 2013 John Wiley & Sons Ltd
Positive affect and negative affect were measured by the
16-item extended version of the Bradhurn Affect Balance
Scale (Bradburn 1969). The scale consisted of nine
items for positive affect and seven items for negative
affect respectively. On a four-point scale (1 as never, 4 as
always), participants were asked to indicate how frequently they experienced the given situations in the
past week. Sample items were ‘things were going your
way’ (positive affect) and ‘very lonely or remote from other
people’ (negative affect). A higher mean score indicated
a high level of the particular affect. The subscales were
reliable and valid in previous studies (Folkman 1997;
Billings et al. 2000). The Cronbach’s alphas for positive
affect and negative affect in this sample were 0.85 and 0.82
respectively.
Self-efficacy to cope with cancer
The 33-item Cancer Behaviour Inventory (CBI) was used
to measure participants’ level of self-efficacy towards
coping with cancer (Merluzzi et al. 2001). On a sevenpoint scale (1 as not at all confident, 7 as totally confident), participants were asked to indicate their general
level of self-confidence when coping with cancer. Sample
items were ‘maintaining work activity’, ‘asking physician
questions’ and ‘remaining relaxed throughout treatment’.
A higher mean score indicated higher self-efficacy. The
scale was reliable and valid in previous studies among
cancer patients (Hochhausen et al. 2007; Mosher et al.
2010). The Cronbach’s alpha in this sample was 0.97.
Quality of life
Quality of life was measured by the Quality of Life –
Cancer Survivors Instrument (QOL-CS) (Ferrell et al.
1995). On a six-point scale (0 as feeling very bad, 5 as
feeling very good), participants were asked to report their
current well-being in four dimensions (physical, psychological, social and spiritual well-being). Sum score of all
items indicated their overall level of well-being, with a
higher score representing better quality of life. The scale
was reliable and highly correlated with the general version
of Functional Assessment of Cancer Therapy (FACT-G)
(Ferrell et al. 1995). The Cronbach’s alpha in this sample
was 0.93.
151
YEUNG & LU
Table 1. Correlations among major variables (n = 238)
(1)
1. Age
2. Gender
3. Education level
4. Marital status
5. Occupation status
6. Time since diagnosis
7. Stage of cancer
8. Self-efficacy
9. Positive affect
10. Negative affect
11. Quality of life
Mean
SD
–
−0.31**
0.13*
−0.07
−0.32**
0.13*
−0.08
0.14*
0.10
−0.25**
0.35**
55.7
9.1
(2)
(3)
(4)
(5)
(6)
–
−0.02
0.21**
−0.07
−0.10
−0.01
−0.07
−0.10
0.10
–
–
–
−0.13
−0.09
−0.14*
0.06
0.15*
0.04
0.07
–
–
–
−0.11
0.01
0.07
−0.02
0.10
−0.02
–
–
(7)
(8)
(9)
(10)
(11)
–
−0.23**
0.45**
2.99
0.68
–
−0.52**
1.73
0.65
–
124.53
24.73
–
0.04
−0.06
0.05
0.11
0.15*
0.02
0.11
0.02
−0.04
–
–
–
0.01
0.08
0.14*
−0.26
0.15*
–
–
–
0.13
−0.01
0.04
−0.19**
–
–
–
0.45**
−0.35**
0.53**
5.01
0.97
*P < 0.05, **P < 0.01.
Coding for variables: Gender: male (1), female (2); Education level: middle school or below (1), high school (2), college or above (3);
Marital status: not married (0), married (1); Occupation status: not full-time employed (0), full-time employed (1); Time since
diagnosis: less than 1 year (1), 1–2 years (2), 2–5 years (3), more than 5 years (4).
Demographic information (including gender, educational level, occupation), disease- and treatment-related
variables (e.g. type of cancer, cancer stage, time since
diagnosis, previous treatments) were also self-reported in
the questionnaire.
0.44
0.30
Analytic plan
RESULTS
Descriptive statistics and correlations among
major variables
Descriptive statistics of major variables and Pearson correlation matrix among the major variables are presented in
152
0.23
Quality of
life
Self-efficacy
–0.35
Descriptive statistics were computed for major variables.
Pearson correlation analysis was conducted to examine the
associations among variables. Missing data were less than
2% in the major psychological variables and were imputed
by expectation-maximisation algorithm (Dempster et al.
1977). These analyses were conducted by SPSS 19.0.
Path analysis was used to evaluate the fitness of the
hypothesised model in explaining the associations among
self-efficacy, affect and quality of life. It was conducted
by M-plus version 5.2 (Muthen & Muthen 2008) with
observed variables and maximum likelihood estimation
method. Model goodness-of-fit was evaluated using several
indices. A Satorra–Bentler scaled chi-square value with
a non-significant P-value (Kelloway 1998), a root mean
square error of approximation (RMSEA) with values 0.08 or
less (Steiger 1990), and a comparative fit index (CFI) and
Tucker–Lewis index (TLI) with values 0.90 or above indicate a satisfactory fit in the model (Hu & Bentler 1999).
Positive
affect
Negative
affect
–0.37
Figure 2. Final model with standardised path coefficients. All
paths significant at P < 0.001.
Table 1. As hypothesised, self-efficacy was associated
with quality of life (r = 0.53, P < 0.01), positive affect (r =
0.45, P < 0.01) and negative affect (r = −0.35, P < 0.01).
Positive affect (r = 0.45, P < 0.01) and negative affect
(r = −0.52, P < 0.01) were also significantly correlated with
quality of life.
Path analysis
Path analysis was conducted to examine the fitness of the
proposed model which hypothesised that affect mediated
the relationship between self-efficacy and quality of life.
This hypothesised model showed a good fit in predicting
quality of life [χ2 (1) = 1.935, P > 0.05, CFI = 0.996; TLI =
0.975; RMSEA = 0.063] (Fig. 2). All paths were statistically
significant (P < 0.001). The associations among the variables remained largely the same even after controlling for
the potential influence of age, cancer stage and time since
diagnosis on quality of life (significant demographic variables correlated with quality of life). The model thus supported the direct effect of self-efficacy on quality of life,
and the indirect effects of self-efficacy on quality of life
© 2013 John Wiley & Sons Ltd
Quality of life among Chinese cancer survivors
through positive affect and negative affect. Specifically,
the indirect effects from self-efficacy to quality of life via
positive affect (β = 0.102, P < 0.001) and via negative
affect (β = 0.129, P < 0.001), were statistically significant.
In the model, self-efficacy explained 19.7% and 12.1% of
variances of positive affect and negative affect. All paths
explained 44.2% of variances of quality of life.
DISCUSSION
This study contributes to the literature by exploring affect
as a mediator to explain the relationship between selfefficacy and quality of life among Chinese cancer patients.
First, we found that self-efficacy was positively associated
with quality of life among Chinese cancer survivors,
in line with Western findings (Hochhausen et al. 2007;
Howsepian & Merluzzi 2009; Mosher et al. 2010). The
beneficial role of self-efficacy to Chinese cancer survivors’
well-being is supported. Second, we found a significant
indirect effect of self-efficacy on quality of life through
both positive affect and negative affect. Qualitative
studies conducted among Chinese cancer survivors have
shown that Chinese people believe that maintenance of
positive states of mind can help to deal with fear of recurrence and promote cancer recovery (Simpson 2005; Hou
et al. 2009; Cheng et al. 2013). Consistent with previous
studies on affect and health outcomes (Howell et al. 2007;
Xu & Roberts 2010; Diener & Chan 2011), our findings
suggest that greater self-efficacy was associated with more
positive affect and less negative affect, which in turn was
associated with better quality of life. The Broaden-andBuild Theory (Fredrickson 2001) may provide an explanation for the findings. It suggests that increasing positive
affect and reducing negative affect could broaden people’s
thought-action repertoires and build resources for coping,
which could in turn facilitate better health outcomes. We
have examined the mediating role of affect between selfefficacy and quality of life among cancer patients as the
first step. We thus recommend future research to take the
next step by examining if the influence of positive affect
and negative affect on quality of life is mediated by people’s coping resources in the context of cancer adaptation.
In addition to affect, other mediators may be at play
between self-efficacy and quality of life among cancer
survivors. Different mediators have been proposed in previous studies among cancer patients. One study showed
that the effect of self-efficacy on quality of life was partially
mediated by perceived stress among 60 cancer survivors in
Israel (Kreitler et al. 2007). Higher self-efficacy was associated with lower perceived stress, which in turn promoted
better quality of life. Another study showed that the effect
© 2013 John Wiley & Sons Ltd
of self-efficacy on benefit finding was mediated by positive
social comparison among 106 post-surgery cancer patients
in Germany (Schulz & Mohamed 2004). A longitudinal
study conducted among patients receiving breast cancer
surgery in Hong Kong showed that the relationship
between self-efficacy and adjustment outcomes was mediated by expectancy-outcome incongruence, which is the
cognitive judgement about congruence between expected
and perceived outcome of the surgery. Higher general
self-efficacy may be associated with expectancy-outcome
incongruence. This in turn led to poorer adjustment
outcomes at 1-month follow-up (Lam & Fielding 2007).
Integrating these findings with ours, it implies that selfefficacy may influence quality of life through both affective
pathways and cognitive-behavioural pathways. Future
studies should explore how these factors may work
together to produce different effects on cancer adjustment.
This study shows that affect explained the link between
self-efficacy and quality of life. While other studies propose
such a link is mediated through cognitive or behavioural
pathways, future research can also compare the relative
prominence of affective, behavioural and cognitive pathways in mediating the influence of different aspects of
self-efficacy (e.g. symptom management, information and
support seeking) on quality of life.
Our findings contradict those of a previous study among
Chinese breast cancer patients in Hong Kong, showing
that self-efficacy may facilitate unrealistic expectancies
about postsurgical outcomes. Potential discrepancies
may be explained by the length of cancer survivorship.
Participants in Lam and Fielding’s study were patients
who had finished breast cancer surgery within a month of
the study, which represents a very different adaptation
stage from our sample. In that study, general self-efficacy
at very early stages of cancer adaptation may involve
an overestimate of personal resources in coping with
stressors, which could lead to incongruence between
expected and actual outcomes. In contrast, our sample had
a high percentage of cancer patients (73.5%) having survived for at least 2 years after diagnosis. They had also
undergone different types of treatment (e.g. surgery,
chemotherapy, and Traditional Chinese Medicine) before
the study. Due to their experiences living with cancer, it
may be easier for our participants to realistically reflect
their personal resources when answering questions related
to self-efficacy for coping with cancer. Self-efficacy measured at a later stage of cancer adaptation may lead to less
incongruence between expected and actual outcomes. To
further validate this claim, future studies should explore
if the effect of self-efficacy and other mediators differ at
different stages of cancer adaptation.
153
YEUNG & LU
This study was subject to several limitations. First, it
was a cross-sectional study, for which a causal relationship could not be inferred. Future studies should investigate the temporal and causal relationships among selfefficacy, affect, and quality of life with longitudinal and
experimental designs. Second, the non-random sample
and self-selection bias in participation might compromise
the generalisability of the findings. Despite these limitations, our findings provide important practical implications. Future interventions should be designed to enhance
cancer survivors’ self-efficacy and positive affect, which
in turn help to increase Chinese cancer survivors’ quality
of life. Self-care skills training sessions are believed to be
useful in increasing self-efficacy for adaptation to cancer
in affective and behavioural aspects. The self-efficacy
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