Support Care Cancer (2014) 22:697–704 DOI 10.1007/s00520-013-2024-z
ORIGINAL ARTICLE
Sources of social support and adjustment among Chinese cancer survivors: gender and age differences Jin You & Qian Lu
Received: 10 April 2013 / Accepted: 18 October 2013 / Published online: 20 November 2013 # Springer-Verlag Berlin Heidelberg 2013
Abstract Introduction Social support has shown to improve adjustment among cancer survivors. However, it is unclear how health benefits of social support depend on the source of support, age, and gender. Chinese culture emphasizes relationship harmony and interdependence, providing a unique opportunity to address these questions. This study investigated how support from different sources was associated with adjustment to cancer and how the association was moderated by gender and age. Methods Chinese cancer survivors (N =238) from Beijing completed a questionnaire packet assessing support from different sources (e.g., family, friends, special others, society, and cancer organization) and adjustment (e.g., quality of life and positive and negative affect). Results Perceived support from family was greater than support from other sources among Chinese cancer survivors. After controlling for support from other sources, greater support from family and society was associated with higher quality of life, more positive affect, and less negative affect. Support from family showed a stronger negative correlation with negative affect among males, and support from special others showed a stronger negative correlation with negative affect among females. Support from society had a stronger positive association with quality of life, and support from friends had a stronger negative association with quality of life among younger survivors than among older survivors. J. You (*) Department of Psychology, Wuhan University, Luojiashan, Wuchang, Hubei 430072, China e-mail: [email protected] Q. Lu (*) Department of Psychology, University of Houston, 126 Heyne Building, Houston, TX 77204, USA e-mail: [email protected]
Conclusions Findings highlight that health benefits of social support depend on the source of support, gender, and age among Chinese cancer survivors. The study has implications for delivering individualized healthcare services tailored to the preferences of cancer survivors based on their cultural backgrounds and demographic characteristics. Keywords Sources of support . Adjustment to cancer . Cancer survivorship . Age . Gender With an increase in survival rate, living with cancer has become a welcomed challenge for survivors worldwide, particularly those from developing countries like China [1]. Literature has demonstrated that social support influences adjustment to cancer, and such effect depends on the sources of support across cultural/ethnic groups [2, 3]. Adjustment to cancer was predicted by support from the spouse among Caucasians [4–6] and was predicted by support from family and friends among cultural/ethnic minority groups [6, 7]. These findings indicate the need to examine health benefits of support from sources other than the spouse among cultural/ ethnic samples. The ecological systems theory [8] argues for the importance of both immediate and distal environments for human functions. However, the effects of support from distal environments (e.g., society) on adjustment remain unknown, particularly among cancer survivors of different age and gender [9, 10]. Chinese culture emphasizes interdependence between individuals, family, non-family others, and society [11], providing an opportunity to address these gaps.
Sources of support and adjustment to cancer Studies have established the relationship between support from the spouse and adjustment to cancer among Caucasians. A
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Support Care Cancer (2014) 22:697–704
qualitative study showed that Caucasian breast cancer survivors primarily relied on support from the spouse [12]. Other studies found that support from the spouse predicted less depression and anxiety among Caucasian breast cancer survivors [6], colorectal cancer survivors [4], prostate cancer survivors [5], and women at high risk for breast and ovarian cancer [13]. Interestingly, findings from non-Caucasian cultural/ethnic samples revealed the association between adjustment to cancer and support from sources other than the spouse. Perceived support from adult children and other family members predicted less anxiety and depression among African–American and Latina breast cancer survivors [6]. Support from family and religious community predicted lower anxiety among Israeli women with advanced breast cancer [7]. Support from close friends predicted lower distress among Hispanic breast cancer survivors [14]. A qualitative study showed that Japanese– American breast cancer survivors relied on more support from close friends and co-workers, while their Chinese counterparts perceived more support from immediate family members [12].
related shifts of social preferences. Findings derived from socio-emotional selectivity theory [16] showed that younger adults preferred to interact with nonfamily others, and older adults prioritized emotionally close others (e.g., family members) [17]. Considering that health benefits of social support depend on receivers' preferences [18], support from nonfamily others may benefit younger survivors more and support from family may benefit older survivors more. Gender may be another moderator because of gender norms. Across cultures, men are expected to be the breadwinner and women are socialized to the nurturer of the family [12, 19]. A study showed that females were more responsive and could provide better support relative to males [20]. Under stressful situations, males depended more on their spouse [19, 21], while females benefited from support from their female friends more due to greater motives of affiliating with other females [22]. Thus, male survivors may benefit more from support from family; female survivors may benefit more from support from other females.
Source-specific support and adjustment to cancer among Chinese cancer survivors
The present study
These cultural/ethnic differences in health benefits of support from different sources may result from social norms within each ethnic/cultural group [6, 12]. Caucasian culture emphasizes the forthcoming “give and take” within the couple [12]. However, other cultures/ethnicities encourage support exchanges among family members and even the greater social network. Thus, providing support to family and close friends in need is perceived as a responsibility in cultural/ethnic groups [6, 12]. With the same logic, we argue that Chinese cancer survivors may rely on and benefit from support from different sources to varying degrees according to Chinese cultural norms. Chinese culture is characterized by family and authority orientations [11]. According to family orientation, Chinese emphasizes interdependence and obligations toward family members, but emphasizes reciprocity and harmony outside of the family [11, 15]. Therefore, Chinese may benefit more from support from family than that from nonfamily members. Additionally, authority orientation [11] suggests that Chinese respect and value the acceptance by societal authority figures based on position, not necessarily on personal qualities. Thus, Chinese may also benefit more from support from society (e.g., government) than that from other sources within the distal environments.
Potential age and gender differences The above associations of support from different sources with adjustment to cancer may be moderated by age due to age-
This study aimed at examining how support from different sources would be associated with adjustment to cancer and how such associations would be moderated by age and gender among Chinese cancer survivors. The ecological systems theory [8] distinguishes between immediate and distal environments. Immediate environments refer to the groups that are physically or psychologically close and exert the most direct impact on individuals; distal environments involve the cultures/institutions in which individuals are embedded. Applying the theory, we conceptualize Chinese cancer survivors' immediate environments as family, friends and special others, and their distal environments as cancer organizations and society. In China, family refers to immediate family members (e.g., spouse, children, parents, and siblings) that are supposed to be interdependent [11]. These immediate family members often live in the same household or close by. Even when they live far away, they are obligated to uphold family members in need due to Confucian family values (e.g., filial piety) [23]. Friends are non-family members with whom individuals build relationships based on companionship or mutual affection [24]. Special others are people who have great importance to an individual's life or well-being; in China, they could be supervisors, colleagues, and relatives. Cancer organizations are nonprofit organizations serving cancer survivors. They often organize social activities and distribute health information for cancer survivors. Society refers to governmental organizations, mass media, and other societal organizations that surround individuals' lives. Stanton and her colleagues propose that adjustment to chronic illness is a multidimensional construct including positive and negative indicators and high
Support Care Cancer (2014) 22:697–704
quality of life [25, 26]. Following their conceptualization, we define adjustment to cancer as positive and negative affect and quality of life. Chinese family orientation [11] and the ecological systems theory [8] concur that family has the strongest influence on individuals. Thus, we hypothesized that (1) support from family would be greater and would show a stronger association with adjustment than support from friends and special others. Based on Chinese authority orientation [11], we hypothesized that (2) support from society would show a stronger association with adjustment than support from cancer organizations. Given age-specific social preferences [17], we hypothesized that (3) support from family would show a stronger association with adjustment among older survivors; support from nonfamily members would show a stronger association with adjustment among younger survivors. Based on gender norms [12, 19], we hypothesized that (4) the association between support from family and adjustment would be stronger among males, while the association between support from friends and special others and adjustment would be stronger among females.
Methods Participants and procedures All participants were recruited from cancer organizations in Beijing, China. Inclusion criteria were (1) being 18 years or older, (2) being diagnosed with cancer, and (3) being able to read and write Chinese. Potential participants were introduced to the study by researchers or volunteers working in the cancer organizations. They were informed of the voluntary and confidential nature of the study. Participants completed a questionnaire packet at home and returned it in a sealed envelope in person to the researchers or volunteers. In total, 238 of 280 contacted participants returned the questionnaires, yielding a response rate of 85 %.
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construct validities among Chinese breast cancer patients [28]. Participants' ratings were made on a 7-point scale ranging from 1 (totally disagree) to 7 (totally agree) and were averaged. Confirmatory factor analysis revealed an adequate model fit for the five-dimensional structure, χ 2 (91)=290.86, p
ORIGINAL ARTICLE
Sources of social support and adjustment among Chinese cancer survivors: gender and age differences Jin You & Qian Lu
Received: 10 April 2013 / Accepted: 18 October 2013 / Published online: 20 November 2013 # Springer-Verlag Berlin Heidelberg 2013
Abstract Introduction Social support has shown to improve adjustment among cancer survivors. However, it is unclear how health benefits of social support depend on the source of support, age, and gender. Chinese culture emphasizes relationship harmony and interdependence, providing a unique opportunity to address these questions. This study investigated how support from different sources was associated with adjustment to cancer and how the association was moderated by gender and age. Methods Chinese cancer survivors (N =238) from Beijing completed a questionnaire packet assessing support from different sources (e.g., family, friends, special others, society, and cancer organization) and adjustment (e.g., quality of life and positive and negative affect). Results Perceived support from family was greater than support from other sources among Chinese cancer survivors. After controlling for support from other sources, greater support from family and society was associated with higher quality of life, more positive affect, and less negative affect. Support from family showed a stronger negative correlation with negative affect among males, and support from special others showed a stronger negative correlation with negative affect among females. Support from society had a stronger positive association with quality of life, and support from friends had a stronger negative association with quality of life among younger survivors than among older survivors. J. You (*) Department of Psychology, Wuhan University, Luojiashan, Wuchang, Hubei 430072, China e-mail: [email protected] Q. Lu (*) Department of Psychology, University of Houston, 126 Heyne Building, Houston, TX 77204, USA e-mail: [email protected]
Conclusions Findings highlight that health benefits of social support depend on the source of support, gender, and age among Chinese cancer survivors. The study has implications for delivering individualized healthcare services tailored to the preferences of cancer survivors based on their cultural backgrounds and demographic characteristics. Keywords Sources of support . Adjustment to cancer . Cancer survivorship . Age . Gender With an increase in survival rate, living with cancer has become a welcomed challenge for survivors worldwide, particularly those from developing countries like China [1]. Literature has demonstrated that social support influences adjustment to cancer, and such effect depends on the sources of support across cultural/ethnic groups [2, 3]. Adjustment to cancer was predicted by support from the spouse among Caucasians [4–6] and was predicted by support from family and friends among cultural/ethnic minority groups [6, 7]. These findings indicate the need to examine health benefits of support from sources other than the spouse among cultural/ ethnic samples. The ecological systems theory [8] argues for the importance of both immediate and distal environments for human functions. However, the effects of support from distal environments (e.g., society) on adjustment remain unknown, particularly among cancer survivors of different age and gender [9, 10]. Chinese culture emphasizes interdependence between individuals, family, non-family others, and society [11], providing an opportunity to address these gaps.
Sources of support and adjustment to cancer Studies have established the relationship between support from the spouse and adjustment to cancer among Caucasians. A
698
Support Care Cancer (2014) 22:697–704
qualitative study showed that Caucasian breast cancer survivors primarily relied on support from the spouse [12]. Other studies found that support from the spouse predicted less depression and anxiety among Caucasian breast cancer survivors [6], colorectal cancer survivors [4], prostate cancer survivors [5], and women at high risk for breast and ovarian cancer [13]. Interestingly, findings from non-Caucasian cultural/ethnic samples revealed the association between adjustment to cancer and support from sources other than the spouse. Perceived support from adult children and other family members predicted less anxiety and depression among African–American and Latina breast cancer survivors [6]. Support from family and religious community predicted lower anxiety among Israeli women with advanced breast cancer [7]. Support from close friends predicted lower distress among Hispanic breast cancer survivors [14]. A qualitative study showed that Japanese– American breast cancer survivors relied on more support from close friends and co-workers, while their Chinese counterparts perceived more support from immediate family members [12].
related shifts of social preferences. Findings derived from socio-emotional selectivity theory [16] showed that younger adults preferred to interact with nonfamily others, and older adults prioritized emotionally close others (e.g., family members) [17]. Considering that health benefits of social support depend on receivers' preferences [18], support from nonfamily others may benefit younger survivors more and support from family may benefit older survivors more. Gender may be another moderator because of gender norms. Across cultures, men are expected to be the breadwinner and women are socialized to the nurturer of the family [12, 19]. A study showed that females were more responsive and could provide better support relative to males [20]. Under stressful situations, males depended more on their spouse [19, 21], while females benefited from support from their female friends more due to greater motives of affiliating with other females [22]. Thus, male survivors may benefit more from support from family; female survivors may benefit more from support from other females.
Source-specific support and adjustment to cancer among Chinese cancer survivors
The present study
These cultural/ethnic differences in health benefits of support from different sources may result from social norms within each ethnic/cultural group [6, 12]. Caucasian culture emphasizes the forthcoming “give and take” within the couple [12]. However, other cultures/ethnicities encourage support exchanges among family members and even the greater social network. Thus, providing support to family and close friends in need is perceived as a responsibility in cultural/ethnic groups [6, 12]. With the same logic, we argue that Chinese cancer survivors may rely on and benefit from support from different sources to varying degrees according to Chinese cultural norms. Chinese culture is characterized by family and authority orientations [11]. According to family orientation, Chinese emphasizes interdependence and obligations toward family members, but emphasizes reciprocity and harmony outside of the family [11, 15]. Therefore, Chinese may benefit more from support from family than that from nonfamily members. Additionally, authority orientation [11] suggests that Chinese respect and value the acceptance by societal authority figures based on position, not necessarily on personal qualities. Thus, Chinese may also benefit more from support from society (e.g., government) than that from other sources within the distal environments.
Potential age and gender differences The above associations of support from different sources with adjustment to cancer may be moderated by age due to age-
This study aimed at examining how support from different sources would be associated with adjustment to cancer and how such associations would be moderated by age and gender among Chinese cancer survivors. The ecological systems theory [8] distinguishes between immediate and distal environments. Immediate environments refer to the groups that are physically or psychologically close and exert the most direct impact on individuals; distal environments involve the cultures/institutions in which individuals are embedded. Applying the theory, we conceptualize Chinese cancer survivors' immediate environments as family, friends and special others, and their distal environments as cancer organizations and society. In China, family refers to immediate family members (e.g., spouse, children, parents, and siblings) that are supposed to be interdependent [11]. These immediate family members often live in the same household or close by. Even when they live far away, they are obligated to uphold family members in need due to Confucian family values (e.g., filial piety) [23]. Friends are non-family members with whom individuals build relationships based on companionship or mutual affection [24]. Special others are people who have great importance to an individual's life or well-being; in China, they could be supervisors, colleagues, and relatives. Cancer organizations are nonprofit organizations serving cancer survivors. They often organize social activities and distribute health information for cancer survivors. Society refers to governmental organizations, mass media, and other societal organizations that surround individuals' lives. Stanton and her colleagues propose that adjustment to chronic illness is a multidimensional construct including positive and negative indicators and high
Support Care Cancer (2014) 22:697–704
quality of life [25, 26]. Following their conceptualization, we define adjustment to cancer as positive and negative affect and quality of life. Chinese family orientation [11] and the ecological systems theory [8] concur that family has the strongest influence on individuals. Thus, we hypothesized that (1) support from family would be greater and would show a stronger association with adjustment than support from friends and special others. Based on Chinese authority orientation [11], we hypothesized that (2) support from society would show a stronger association with adjustment than support from cancer organizations. Given age-specific social preferences [17], we hypothesized that (3) support from family would show a stronger association with adjustment among older survivors; support from nonfamily members would show a stronger association with adjustment among younger survivors. Based on gender norms [12, 19], we hypothesized that (4) the association between support from family and adjustment would be stronger among males, while the association between support from friends and special others and adjustment would be stronger among females.
Methods Participants and procedures All participants were recruited from cancer organizations in Beijing, China. Inclusion criteria were (1) being 18 years or older, (2) being diagnosed with cancer, and (3) being able to read and write Chinese. Potential participants were introduced to the study by researchers or volunteers working in the cancer organizations. They were informed of the voluntary and confidential nature of the study. Participants completed a questionnaire packet at home and returned it in a sealed envelope in person to the researchers or volunteers. In total, 238 of 280 contacted participants returned the questionnaires, yielding a response rate of 85 %.
699
construct validities among Chinese breast cancer patients [28]. Participants' ratings were made on a 7-point scale ranging from 1 (totally disagree) to 7 (totally agree) and were averaged. Confirmatory factor analysis revealed an adequate model fit for the five-dimensional structure, χ 2 (91)=290.86, p
