Ambivalence over emotional expression and physical functioning and limitations: mediating and moderating effects of PTSD symptoms and acculturation among Chinese breast cancer survivors

  • Ivan H. C. Wu
  • Lorna H. McNeill
  • Qian Lu
Original Article



The psychosocial correlates of physical functioning and limitations are not well-known among Chinese breast cancer survivors. Previous research suggests a link between ambivalence over emotional expression (AEE) and physical functioning. The current study built upon this research by examining post-traumatic stress symptoms (PTSS) as a mechanism. Further, we also examined the moderating effects of mainstream cultural orientation. To this end, we tested study hypotheses using moderated mediation models.


Participants were 96 Chinese-speaking breast cancer survivors in the USA. Participants were diagnosed within the past five years with stages 0–III breast cancer. Participants completed questionnaires related to AEE, PTSS, SF-36 physical functioning, and role limitations due to physical health subscales, and acculturation.


Results from moderated mediation models provided support for study hypotheses. AEE was positively related to overall PTSS and its three subscales (i.e., re-experiencing symptoms, avoidance, and arousal). Further, PTSS and the three subscales were negatively related to physical functioning and positively related to role limitations due to physical health. The indirect effects of AEE on physical functioning and role limitations due to physical health through PTSS and the three subscales were significant. Moderated mediation models showed that the indirect effects of AEE on physical functioning through PTSS and the re-experiencing subscale were stronger for those high, compared to low, in mainstream culture orientation.


Those with high AEE experience had worse physical functioning and greater role limitations due to increased PTSS. However, the indirect effects were stronger for those who endorse greater mainstream culture. Implications for results suggest that interventions aimed at addressing AEE and PTSS may help alleviate physical health problems especially those high in mainstream culture orientation.


Ambivalence over emotional expression Physical functioning Post-traumatic stress symptoms Acculturation Cancer survivors 


Funding information

Ivan H.C. Wu, Ph.D., and the research were supported, in part, by the Cancer Prevention and Research Institute of Texas (CPRIT) award ID RP170259 (Shine Chang, Ph.D., and Sanjay Shete, Ph.D., Principal Investigators), the MD Anderson’s Cancer Center Support Grant (CA016672, Peter Pisters, M.D., Principal Investigator) funded by the National Cancer Institute, and a grant from the University of Texas MD Anderson Cancer Center Duncan Family Institute for Cancer Prevention and Risk Assessment.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest. Primary author has full control of all primary data and is willing to provide data upon request for reviewers.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Health Disparities ResearchMD Anderson Cancer CenterHoustonUSA
  2. 2.Department of PsychologyUniversity of HoustonHoustonUSA

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