The findings of this study indicated that coping styles, perceived social support, and resilience were predictors of HRQoL; resilience was influenced by coping styles and perceived social support, and had a mediating role between coping styles, perceived social support, and HRQoL.
The correlation findings demonstrated that confrontation was associated with better perceived social support and resilience, and better perceived social support was associated with higher resilience. This reflects the fact that positive psychological states can be shown in different aspects, and are positively correlated with each other . Consistent with previous reports, it was found that confrontation, perceived social support, and resilience were positively associated with HRQoL, which indicated that a sound psychological state was beneficial to HRQoL improvement [8,9,10,11,12]. Although avoidance is a negative coping style, it was still helpful in protecting the BCSs’ psychological defense system, which allowed more time for them to recover from their distress .
The multivariate linear regression analysis found that perceived social support was not a significant predictor of HRQoL when sociodemographic factors, clinical characteristics, and other psychological factors were considered. This is inconsistent with previous reports [12, 13]. Although we found that perceived social support was significantly positively correlated with HRQoL, it could be influenced by negative psychological factors, such as resignation. After we excluded the resignation variable from the regression model, perceived social support was found to be a significant predictor of HRQoL. This finding indicates that it is important to pay attention to negative psychological states, which will help in avoiding the weakening or offsetting effects on the benefits of positive psychological states.
Confrontation and perceived social support were positive predictors of resilience, while resignation was a negative predictor. This suggests that interventions should focus on coping styles and perception of social support while managing resilience, as suggested by the findings of similar studies [12, 13, 25]. Resilience was found to be lower in BCSs who were not receiving endocrine therapy, were living in a rural location, and had no chronic disease. This is probably because: (1) the BCSs not receiving endocrine therapy might have a special pathological type that is not suitable for receiving endocrine therapy, which would lead them to worry about their prognosis, and consequently decrease their resilience; (2) the BCSs living in rural locations might lack information about treatment, prognosis, and self-care, which would lead to a sense of uncertainty and lower their resilience; (3) the BCSs with no chronic disease who had good health status, may experience severe psychological distress after being diagnosed with breast cancer, which would lead to low resilience. Although the above characteristics of BCSs had no clear relationship with low resilience on the surface, their poor psychological states might be related closely to low resilience [26,27,28]. Thus, healthcare providers should pay more attention to BCSs with these characteristics, to enhance their resilience and support the improvement of their HRQoL.
Resilience was a significant mediator between confrontation/resignation, perceived social support, and HRQoL, indicating that it has an important role in strengthening the positive influences of confrontation and perceived social support, or weakening the negative influences of resignation, on HRQoL. The findings of this study further support the role of resilience, that is, an individual’s ability to adapt and successfully cope with adversity [11, 29,30,31,32]. The final SEM results support the three hypotheses of this study and suggest that strengthening resilience would enhance the intervention effects regarding coping styles and perception of social support, which will improve HRQoL.
Although avoidance was positively correlated with HRQoL, it had no significant direct effect on resilience and no significant indirect effect on HRQoL via resilience. This is probably due to the weak correlation between these variables in our study sample. Considering the protecting role of avoidance under certain circumstances, the influences of avoidance on resilience and HRQoL should be further explored.
The study findings have important implications for clinical practice and the development of intervention programs to improve resilience and the HRQoL of BCSs. According to our findings, more resources regarding psychological support should be provided in health management programs for BCSs. Additionally, healthcare providers should focus more on resilience and coping while informing the patient of the breast cancer diagnosis, which would help decrease the patient’s psychological trauma during the treatment and long-term rehabilitation process from the beginning. Moreover, the findings also suggest that resilience-oriented interventions would be effective in alleviating the detrimental influences of low resilience on HRQoL, providing a new strategy for improving health status regarding BCSs.
The study had some limitations. First, since coping styles, perceived social support, resilience and HRQoL were measured using self-reported data, the relationships among these variables might be susceptible to response bias. Second, causal relationships could not be identified due to the cross-sectional design. Longitudinal studies are recommended in future work to further explore the relationship trajectories during long-term rehabilitation. Third, the study was conducted in Xi’an, which limited the generalizability of the findings.