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The Dyadic Effects of Self-Efficacy on Quality of Life in Advanced Cancer Patient and Family Caregiver Dyads: The Mediating Role of Benefit Finding, Anxiety, and Depression
The Dyadic Effects of Self-Efficacy on Quality of Life in Advanced Cancer Patient and Family...
Cao, Qian;Gong, Jiali;Chen, Meizhen;Lin, Yi;Li, Qiuping
2022-09-13 00:00:00
Hindawi Journal of Oncology Volume 2022, Article ID 3073358, 9 pages https://doi.org/10.1155/2022/3073358 Research Article The Dyadic Effects of Self-Efficacy on Quality of Life in Advanced Cancer Patient and Family Caregiver Dyads: The Mediating Role of Benefit Finding, Anxiety, and Depression 1 1 1 1 1,2 Qian Cao , Jiali Gong , Meizhen Chen , Yi Lin , and Qiuping Li Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China Aliated Hospital, Jiangnan University, Wuxi, Jiangsu, China Correspondence should be addressed to Qiuping Li; qiuping.li@connect.polyu.hk Received 22 May 2022; Accepted 22 August 2022; Published 13 September 2022 Academic Editor: Jayaprakash Kolla Copyright © 2022 Qian Cao et al. �is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. To explore the dyadic interdependence of self-e„cacy, bene…t …nding, anxiety, depression, and QOL in cancer patient (CP) and family caregiver (FC) dyads, and to ascertain the dyadic e‹ects of self-e„cacy on quality of life (QOL) in CP-FC dyads. Methods. Conducted from November 2014 to December 2015, participants comprised 772 CP-FC dyads. �e study surveyed participant characteristics, self-e„cacy, bene…t …nding, anxiety, depression, and QOL. Data were analyzed using Pearson’s correlation, T-test, and actor-partner interdependence mediation model (APIMeM). Results. CPs’ self-e„cacy was positively correlated with both their own and FCs’ bene…t …nding and mental component summary (MCS), and negatively associated with anxiety and depression (all Ps < 0.01, |r| = 0.144∼0.432). However, CPs’ self-e„cacy was only positively correlated with their own physical component summary (PCS) (r = 0.193), but not FCs’ PCS. �e same pro…le was identi…ed in FCs’ self-e„cacy (all Ps < 0.01, |r| = 0.100∼0.468). FCs reported higher levels of self-e„cacy and PCS compared to CPs (both Ps < 0.001). Signi…cant positive correlations (r = 0.168–0.437) were identi…ed among all paired variables in CP-FC dyads (all Ps < 0.001). To some extent, dyads’ self-e„cacy in¤uences dyads’ MCS and PCS through improving positive emotions (bene…t …nding) and relieving negative emotions (anxiety and depression). Conclusions. Study …ndings not only support the dyadic interdependence of self-e„cacy, bene…t …nding, anxiety, depression, and QOL in CP-FC dyads but con…rm the hypothesis that dyads’ self-e„cacy may impact their MCS/PCS via an indirect approach to improve bene…t …nding and relieve anxiety and/or depression in CP-FC dyads. experiences, such as improved self-e„cacy, adjusted life 1. Introduction priorities, and increased family interactions [6–9]. �is A cancer diagnosis, particularly a diagnosis of advanced phenomenon is mirrored in the revised stress and coping cancer, cancer treatment, and survivorship are adverse and model (SCM), in that positive emotions/e‹ects co-occur stressful events for both cancer patients (CPs) and their along with the inevitable negative emotions/e‹ects in- family caregivers (FCs) [1]. Advanced cancer generally herent in the circumstance of an extremely stressful event, denotes incurable cancer, as the CP’s situation gradually e.g., advanced cancer and caregiving [10]. As an appraisal- deteriorates [1]. During the stressful advanced cancer tra- based model, SCM [11] proposes that individuals’ cognitive jectory, both CPs and their FCs need to cope together and appraisals of their stress (primary appraisal) and coping adjust to these adversities of profound physical, emotional, (secondary appraisal) experiences trigger the coping process. and social adversity, including psychological distress, fa- In the context of advanced cancer coping process, primary tigue, and impaired quality of life (QOL), imposed by ad- appraisals refer to individuals, CPs and FCs in this case, who vanced cancer and/or caregiving [2–5]. evaluate the personal signi…cance of the stressful event like Fortunately, as they progress and adapt to the coping advanced cancer [1], e.g., the ways in which cancer or process, CP-FC dyads may thrive and undergo positive caregiving trajectory a‹ects or threatens their lives and 2 Journal of Oncology negatively correlated with dyads’ anxiety and depression; livelihood. Secondary appraisals are evaluations of their capabilitytomanagecancerorcaregivingconsequences,e.g., dyadic interdependence of self-efficacy, benefit finding, anxiety, depression, and QOL would exist in CP-FC dyads; their self-efficacy in coping with cancer or the caregiving situation [1]. Self-efficacy in coping with cancer is con- and self-efficacy could influence dyads’ QOL via improving ceptualized as a specific construct that facilitates CPs’ ability positive emotions (benefit finding) and relieving negative to adjust their behaviors, and stabilize their emotions in the emotions (psychological distress). trajectory of coping with cancer, ranging from cancer di- agnosis and cancer treatment to survivorship care [12–15]. 2. Methods Indeed, evidence has shown that self-efficacy plays an &e data in this analysis were extracted from a project study important role in CPs’ response to stressors associated with onChinese CP-FCdyads. Whiletheprevious studyexplored a cancer diagnosis, treatment, and survivorship [1, 15]. the factor structure of the 17-item Benefit Finding Scale Findings in the area of psychosocial oncology have also (BFS) [26], the Cancer Behavior Inventory-brief (CBI–B) revealed the fact that the higher the levels of self-efficacy, the [27], and identified moderating factors for the benefit fewer the negative emotions, e.g., anxiety and depression, finding associations in CP- FC dyads [6], the main focus of and the better the QOL [13, 15–18]. It deserves noting that this analysis was to disclose the dyadic impact of self-efficacy the majority of these studies targeted CPs or cancer survi- on QOL in CP-FC dyads. Participants included CP-FC vors. However, few researchers have discovered the re- dyads. CPshad aconfirmedcancer diagnosisandwere being lationship between self-efficacy and positive emotions, e.g., cared for by a family caregiver, namely FC. Moreover, both benefit findings [19]. Study gaps also exist concerning the CPs and FCs were adults (>18 years old). possible mechanism contributing to the interrelationships Regarding the sample size, the 772 CP-FC dyads that between these variables, e.g., whether emotional outcomes were included were calculated based on the sample re- (e.g., positive or negative emotions) can mediate the effects quirement for factor analysis in the previous study [26]. In of self-efficacy on favorable outcomes, e.g., improved QOL addition, according to the APIM power analysis, there is remains unknown. virtually 1.00 power to detect an actor and/or partner effect Considering interpersonal influences on cancer-related for Person 1 or Person 2 of a size 0.150 in a standardized outcomes in CP-FC dyads, the Actor-Partner in- regression coefficient [28]. terdependence model (APIM) allows researchers to explore theimpactof anindividual’s predictor variable(e.g., CP self- efficacy) on his/her own outcome variables (e.g., QOL of 2.1. Instruments. A self-developed inquiry form was used to CPs, named the actor effect) and on the partner’s outcome solicit CP-FC dyad characteristics, e.g., age, gender, FC variables (e.g., FC QOL, the partner effect) using dyadic data relationship with CP, employment status, cancer type, and [20, 21]. Further, an extension of APIM, the Actor-Partner average time since diagnosis (Table 1). Additionally, the Interdependence Mediation Model (APIMeM), makes it following four types of variables were collected: possible to estimate the mediation or indirect effects of the (i) Self-efficacy: Self-efficacy was assessed by the 12- dyadic impact by adding athird variable [22],e.g., toexplore item CBI-B [15]. CBI-B is designed to estimate the possible mediating effects of positive or negative emo- participants’ confidence in their ability to perform tions on the important impact of CP-FC dyads’ self-efficacy a particular activity associated with self-efficacy in on their QOL in the current study. Indeed, APIM or the cancer-coping process [15]. Items were calcu- APIMeM has been profoundly applied in a dyadic context of lated using a nine-point option (1–9), indicating CP-FC dyads, showing dyadic interdependence in various different confidence levels ranging from not at all variables, indicating psychosocial well-being, e.g., de- (1), moderately (5), tototally (9). &e 12-item scores pression, anxiety, positive affect, and personal growth were summed to provide the CBI-B total score, with [2–4, 8, 23–25] Nevertheless, no study to date has reported higher scores (ranging between 12 and 108) signi- the interdependence between the variables of self-efficacy, fying better self-efficacy. A previous study on the benefit finding, anxiety, depression, and QOL in Chinese Chinese version CBI-B (CBI–B/C) has offered CP-FC dyads using APIM or APIMeM analysis. a satisfactory single-factor construct and good in- Tofillinthesestudygaps,thecurrentstudywasintended ternal stability in CP-FC dyads [27]. to investigate the interdependences of these outcome vari- ables, e.g., self-efficacy benefit finding, anxiety, depression, (ii) Benefit finding: &e 17-item BFS was used to ex- and QOL, in CP-FC dyads from a dyadic perspective. Ac- amine benefit findings [29]. &e BFS has been cordingly, the study aims were: (i) to assess correlations widely applied and validated in either CPs [29, 30] between dyads’ (both CP and FC) self-efficacy and other or FCs [31]. &e BFS items are scored using a five- variables,e.g.,benefitfinding,anxiety,depression,andQOL, point (1–5) scale option, and the BFS total score is (ii) to examine the mutual relationship of the outcome reached by adding up the 17 individual items that variables, including self-efficacy, benefit finding, anxiety, were included. &e higher the BFS score (range depression, and QOL, between CP-FC dyads, and (iii) to 17–85), the better the benefit finding. A previous ascertain the effects of self-efficacy on QOL in CP-FC dyads. study on the Chinese version of BFS (C–BFS) has It was hypothesized that dyads’ self-efficacy would be pos- established a three-factor validity and good internal itively associated with dyads’ benefit finding and QOL, stability in CP-FC dyads [26]. Journal of Oncology 3 Table 1: Characteristics of cancer patients and family caregivers. Characteristics Patients [ n (%)] FC [ n (%)] Age (mean±SD), years 55.1±12.7 (range: 18–88) 48.3±13.4 (range: 18–80) Gender Male 403 (52.2) 360 (46.6) Female 367 (47.5) 411 (53.2) Missing data 2 (0.3) 1 (0.2) Marital status Married 717 (92.9) 702 (90.9) Divorced 10 (1.3) 2 (0.3) Widowed 21 (2.7) 2 (0.3) Never married 24 (3.1) 65 (8.4) Missing data 0 (0.0) 1 (0.1) FC relationship with patients Spouse 474 (61.4) Offspring 215 (27.8) Parent 20 (2.6) Sibling 41 (5.3) Other 21 (2.7) Missing data 1 (0.2) Education levels Primary school or less 420 (54.4) 323 (41.8) High school 247 (32.0) 271 (35.1) University or above 103 (13.3) 174 (22.5) Missing data 2 (0.3) 4 (0.6) Employment status Employed 440 (57.0) 467 (60.5) Not-employed 327 (42.4) 302 (39.1) Missing data 5 (0.6) 3 (0.4) Type of cancer Breast cancer 79 (10.2) Ovarian and cervical cancer 95 (12.3) Esophageal and gastric cancer 186 (24.1) Colorectal cancer 113 (14.6) Liver cancer 69 (8.9) Lung cancer 122 (15.8) Others 91 (11.8) Missing data 17 (2.2) Average time since diagnosis (mean±SD), months 12.9±12.5 (range: 3–192) Note: FC �family caregivers; SD �standard deviation. All cancer patients were diagnosed at an advanced stage of the disease. (iii) Anxiety and depression: &e Hospital Anxiety 2.2. Procedures. After obtaining ethical authorization from the university’s ethics board (HSEARS201410005), and and Depression Scale (HADS) was applied to evaluate anxiety and depression [32]. A four- written informed consent from eligible CP-FC dyads, the point (0–3) scale option was used to score each CP-FC dyads were then guided to independently fill out the item. Anxiety and depression scores were gen- survey. &e survey was administered from November 2014 erated by adding up the seven individual items to December 2015 at two hospitals in Wuxi, China. that were included, with higher scores demon- strating higher levels of anxiety or depression. 2.3. Data Analysis. SPSS and Amos version 22.0 were ap- Study findings using the HADS Chinese version plied toanalyze thedata. CP-FC dyad characteristics andthe in Chinese CP-FC dyads have confirmed its four outcome measures (CBI–B, BFS, HADS, and SF-12) are applicability and validity [33]. presented using descriptive statistics. &e mean differences (iv) QOL: QOL was calculated using the medical out- in paired outcome measures between CPs and FCs were comes study 12-item short-form version 2 (SF-12 examined using paired T-test. Pearson correlations were v2) [34]. According to the SF-12 score guidebook used to investigate variable correlations between CPs [35], the two aggregate scores of mental component and FCs. summary (MCS) and physical component Sum- &e APIMeM was applied to uncover the dyadic effects mary (PCS) were reached, with a scale ranging of self-efficacy on dyads’ QOL [20–22], using self-efficacy to between 0 and 100. &e higher the score, the better predict QOL through benefit finding (Figure S1) and psy- the QOL [35]. chological distress respectively (Figure S2). Given the fact 4 Journal of Oncology that anxiety and depression are generally highly associated 3.3. Dyadic Impact of Self-Efficacy on QOL. Part(a) inTable4 with one another (in the current sample, values of r were and Figure S3 show the effects of self-efficacy on QOL mediated by benefit findings. For the effects of self-efficacy 0.833 and 0.835 for CPs and FCs respectively), a latent variable, designated by anxiety and depression, was treated on benefit finding, there were four significant positive actor as psychological distress. In the APIMeM, 1 and 2 were effects (a A1, a A2, all Ps<0.001), and two significant labelsforCPsandFCs,respectively.&eeffectofself-efficacy positive CP partner effects (a P1, all Ps<0.001). For the on benefit finding (Figure S1)/psychological distress (Figure b effects, there was one significant positive FC actor effect (b S2) is labeled “a,” the effect of benefit finding/psychological A2, P � 0.024), and one borderline negative CP partner distressonQOLas“b,”andtheeffectofself-efficacyonQOL effect (bP1, P � 0.072) from benefit finding to MCS in as “c.” &e actor effect [the impact of an individual’s pre- submodel MCS. In submodel PCS, one borderline positive dictor variable (e.g., self-efficacy of CPs) on his/her own FC partner effect (bP2, P � 0.066) from benefit finding to PCS was identified. For the c’ effects of self-efficacy on QOL: outcomevariables(e.g.,QOLofCPs)]andpartnereffect[the impactofanindividual’spredictorvariable(e.g.,self-efficacy four significant positive direct actor effects of self-efficacy on both MCS and PCS (c’A1, c’A2, all Ps<0.001) were of CPs) on the partner’s outcome variables (e.g., QOL of FCs)] were indexed as A and P, respectively [20–22]. &e identified. significance of total effect or total indirect effect (IEs) was Part (b) in Table 4 and Figure S4 present the effects of evaluated by conducting the bias-corrected bootstrap test self-efficacyonQOL,mediatedbypsychologicaldistress.For with a 95% confidence interval. the effects of self-efficacy on psychological distress: four significant negative actor effects (a A1 and a A2, all Ps<0.001) and two negative FC partner effects (a P2, all 3. Results Ps<0.05) were identified. For the b effects from psycho- Among the 772 dyads, all CPs had advanced cancer. And logical distress to QOL: all four negative actor effects (b A1 morethan90%ofparticipantsweremarried.&emajorityof and b A2, all Ps<0.001) were significant. In submodel MCS, FCs (61.4%) were spouses. Approximately three-fifths one borderline negative CP partner effect (bP1, P � 0.069) (57.0% and 60.5% for CPs and FCs, respectively) were wasrecognized.Forthec’effectsofself-efficacyonQOL,two employed (Table 1). significant positive actor effects (c’A1 and c’A2, P � 0.004 and 0.001 respectively) in submodel MCS, and one signif- icant positive FC actor effect (c’A2, P<0.001) in submodel 3.1. Correlations between Dyads’ Self-Efficacy and Other PCS were found. Variables. Table 2 shows correlations between dyads’ (both Table 5 presents the bias-corrected bootstrap tests of the CP and FC) self-efficacy and other outcome variables in CPs total effects, total IEs, and direct effects. In model a: effects of and FCs. At the individual level, CP findings showed that self-efficacy on QOL mediated by benefit finding are shown in self-efficacy was positively related to benefit finding, MCS, 5(a) in Table 5. For actor effects: there were four significant CP and PCS (r �0.193∼0.432), and negatively associated with actor effects (total and direct effects, all Ps �0.001), four sig- anxiety (r � −0.418) and depression (r � −0.430). &e same nificant FC actor effects (total and direct effects, all Ps �0.001), profile was identified for FC variables (|r| �0.241∼0.468). andoneborderlineFCtotalIEs(P � 0.051)insubmodelMCS. At the dyadic level, correlations between dyads’ self- For partner effects: one borderline CP total IEs (P � 0.066) in efficacy and other variables in their partners showed that submodelMCS,andoneborderlineFCtotalIEs(P � 0.056)in self-efficacy in CPs was significantly correlated with other FC submodel PCS were identified. variables (CP1: Self-efficacy column), including benefit In model b: effects of self-efficacy on QOL mediated by finding (r �0.194), anxiety (r � −0.187), depression psychological distress are presented in part (b) in Table 5. (r � −0.188), and MCS (r �0.144), with the exception of For actor effects: apart from CP direct effect c’, all other 11 borderline correlation with PCS (r �0.071, P � 0.058). &e actor effects (11/12) in both submodels were statistically same profile was identified for self-efficacy in FCs (FC1: Self- positive significant (P � 0.011 ∼ 0.001). For partner effects: efficacy column), where self-efficacy in FCs was significantly one significant positiveFC total IEs (P � 0.012) in submodel correlated with CPs’ benefit finding (r �0.319), anxiety MCS, and two borderline FC partner effects (positive total (r � −0.164),depression (r � −0.190),andMCS (r �0.100),but IEs, P � 0.078, and negative direct effect c’, P � 0.079) in not PCS. All of the above significant correlations are at the submodel PCS were identified. P<0.001 level, with one exception of P � 0.007 for a corre- Part (c) in Table 5 shows the total IEs of self-efficacy on lation between FCs’ self-efficacy and CPs’ MCS. anxiety or depression. For actor effects: all eight IEs in both CPs and FCs were negatively significant (all Ps �0.001). For 3.2. Dyadic Relationship of Outcome Variables. Table 3 partner effects: two negative significant FC total IEs (all presents Pearson correlations and paired differences of all of the Ps<0.05)insubmodelMCS,andtwonegativeborderlineFC outcome variables between CPs and FCs. Significant positive total IEs (P � 0.068, and 0.071 respectively) in submodel correlations (r �0.168–0.437) were identified among all of the PCS were identified. It is worth noting that although no significant CP partner effects were identified, all four CP paired variables, including self-efficacy, benefit finding, anxiety, depression, MCS, and PCS, in CP-FC dyads (all Ps<0.001). In partnereffectswerepositiveintermsoftheireffectdirection, which are different from other effects, e.g., CP and FC actor terms of differences, FCs reported higher levels of self-efficacy and PCS compared to CPs (both Ps<0.001). effect, and FC partner effect. Journal of Oncology 5 Table 2: Correlations between self-efficacy and other outcome variables in cancer patients and family caregivers dyads (n �772). Variables CP1: self-efficacy P value FC1: self-efficacy P value Variables of cancer patients CP1: self-efficacy — 0.418 <0.001 CP2: benefit finding 0.432 <0.001 0.319 <0.001 CP3: anxiety −0.418 <0.001 −0.164 <0.001 CP4: depression −0.430 <0.001 −0.190 <0.001 CP5: MCS 0.339 <0.001 0.100 0.007 CP6: PCSDSB 0.193 <0.001 0.047 0.215 Variables of family caregivers FC1: self-efficacy 0.418 <0.001 — FC2: benefit finding 0.194 <0.001 0.468 <0.001 FC3: anxiety −0.187 <0.001 −0.296 <0.001 FC4: depression −0.188 <0.001 −0.351 <0.001 FC5: MCS 0.144 <0.001 0.281 <0.001 FC6: PCS 0.071 0.058 0.241 <0.001 Note: CP �cancer patients; FC �family caregivers; MCS �mental component summary; PCS �physical component summary. Table 3: Pearson correlations and paired differences of all the outcome variables between cancer patients and family caregivers (n �772). Cancer patients Family caregivers Outcome variables r P value t P value (mean±SD) (mean±SD) Self-efficacy 76.1±19.5 81.2±17.5 0.418 <0.001 −7.473 <0.001 Benefit finding 59.7±13.7 60.1±13.8 0.437 <0.001 −0.788 0.431 Anxiety 8.6±4.5 8.8±4.4 0.338 <0.001 −0.798 0.425 Depression 8.3±4.9 8.5±4.7 0.330 <0.001 −0.879 0.380 MCS 41.3±8.4 41.9±7.9 0.217 <0.001 −1.398 0.163 PCS 36.4±8.9 45.1±8.7 0.168 <0.001 −20.235 <0.001 Note: MCS �mental component summary; PCS �physical component summary; SD �standard deviation. either CPs or FCs. In general, the significant dyadic cor- 4. Discussion relations between dyads’ self-efficacy and other variables are &is study aimed to scrutinize the relationships between in line with the findings of other studies on couples dealing the variables of self-efficacy, benefit finding, anxiety, with cancer together [36, 37]. Another study revealed that depression, and QOL, and to ascertain the dyadic influ- self-efficacy is a factor that moderates benefit-finding cor- ence of self-efficacy on QOL in CP-FC dyads. Study relations in CP-FC dyads [6]. &ese findings may indicate findings, generally, support our hypothesis that dyads’ that dyadic interdependence exists in CP-FC dyads in their self-efficacy is positively associated with dyads’ benefit journey of dealing with cancer as a unit. findings and QOL, and negatively correlated with dyads’ anxiety and depression. &ey also support that dyadic 4.2. Dyadic Relationship of Outcome Variables. Findings of interdependence exists between variables of self-efficacy, the significant correlations between all of the paired vari- benefit finding, anxiety, depression, and QOL; and that ables, e.g., self-efficacy, benefit finding, anxiety, depression, self-efficacy could exert an impact on dyads’ QOL through and QOL, between CP-FC dyads are similar to previous improving positive emotions (benefit finding) and re- findings in a sample of cancer couple dyads [36]. &ese lieving negative emotions (psychological distress). &e findings further confirm the dyadic interdependence be- following discussion will mainly focus on the three cor- tween CPs and FCs in terms of self-efficacy, benefit finding, responding aspects, as indicated in the study aims and anxiety, depression, and QOL. hypothesis. In terms of differences in the paired outcome variables between CPs and FCs, it is reasonable that CPs experienced lower levels of self-efficacy and PCS than FCs because CPs 4.1. Correlations between Dyads’ Self-Efficacy and Other Variables. At the individual level of CPs or FCs, findings of sufferfromtheeffectsofadvancedcancerand itstreatment. Findings of lower levels of PCS in CPs than in FCs are in significant positive associations between self-efficacy and their own QOL, and negative associations between self- line with another sample finding in Chinese couples coping with advanced cancer [4]. &is generally poor QOL in efficacy and anxiety/depression, were consistent with other study findings in various cancer populations, as de- CP-FC dyads serves as a call for further studies, to develop scribed earlier [13, 15–18]. Few studies have focused on the more effective interventions for improving CP-FC dyad QOL. associations between self-efficacy and benefit finding in 6 Journal of Oncology Table 4: Effect estimates for cancer patients and family caregivers. Submodel MCS Submodel PCS Effect Estimate SE P value Standard estimate Estimate SE P value Standard estimate 4(a): effects on QOL mediated by BF (model a) (a): effects (self-E⟶BF) CP actor effect (a A1) 0.246 0.028 <0.001 0.349 0.246 0.028 <0.001 0.349 FC actor effect (a A2) 0.355 0.031 <0.001 0.451 0.355 0.031 <0.001 0.451 CP partner effect (a P1) 0.122 0.031 <0.001 0.153 0.122 0.031 <0.001 0.153 FC partner effect (a P2) −0.009 0.027 0.742 −0.013 −0.009 0.027 0.742 −0.013 (b): effects (BF⟶QOL) CP actor effect (b A1) 0.019 0.026 0.474 0.032 0.014 0.030 0.631 0.022 FC actor effect (b A2) 0.059 0.026 0.024 0.102 0.005 0.029 0.873 0.007 CP partner effect (b P1) −0.048 0.027 0.072 −0.080 0.008 0.030 0.791 0.012 FC partner effect (b P2) −0.010 0.026 0.694 −0.018 0.053 0.029 0.066 0.084 (c’): effects (self-E⟶QOL) CP actor effect (c’ A1) 0.144 0.018 <0.001 0.343 0.088 0.021 <0.001 0.194 FC actor effect (c’ A2) 0.105 0.021 <0.001 0.230 0.114 0.023 <0.001 0.227 CP partner effect (c’ P1) −0.007 0.021 0.731 −0.015 −0.027 0.024 0.252 −0.054 FC partner effect (c’ P2) 0.022 0.018 0.227 0.053 −0.025 0.020 0.209 −0.057 4(b): effects on QOL mediated by PD (model b) (a): effects (self-E⟶PD) CP actor effect (a A1) −0.104 0.009 <0.001 −0.486 −0.101 0.009 <0.001 −0.483 FC actor effect (a A2) −0.076 0.011 <0.001 −0.308 −0.081 0.011 <0.001 −0.320 CP partner effect (a P1) 0.007 0.010 0.492 0.028 0.006 0.010 0.544 0.025 FC partner effect (a P2) −0.021 0.009 0.027 −0.095 −0.019 0.010 0.049 −0.085 (b): effects (PD⟶QOL) CP actor effect (b A1) −0.921 0.087 <0.001 −0.468 −0.703 0.104 <0.001 −0.324 FC actor effect (b A2) −0.907 0.078 <0.001 −0.491 −0.636 0.091 <0.001 −0.323 CP partner effect (b P1) −0.141 0.078 0.069 −0.074 −0.147 0.089 0.101 −0.073 FC partner effect (b P2) −0.125 0.081 0.123 −0.066 −0.086 0.101 0.398 −0.040 (c’): effects (self-E ⟶QOL) CP actor effect (c’ A1) 0.051 0.017 0.004 0.121 0.018 0.021 0.399 0.039 FC actor effect (c’ A2) 0.056 0.018 0.001 0.123 0.071 0.021 <0.001 0.141 CP partner effect (c’ P1) −0.027 0.018 0.145 −0.057 −0.031 0.022 0.164 −0.060 FC partner effect (c’ P2) −0.013 0.017 0.428 −0.033 −0.033 0.020 0.105 −0.074 Note: BF �benefit finding; MCS �mental component summary; PCS �physical component summary; PD �psychological distress; QOL �quality of life; SE �standard error; Self-E �self-efficacy; 1 �CP �cancer patients; 2 �FC �family caregivers. Further analysis of model a (part (a) in Table 4) 4.3. Dyadic Impact of Self-Efficacy on QOL. Discoveriesofthe two APIMeM models further support the interdependence revealed a positive influence of self-efficacy on benefit ofself-efficacy,benefitfinding,anxiety,depression,andQOL finding (A1, A2, and P1), with the latter (benefit finding) in CP-FC dyads. &is indicates that dyads’ self-efficacy may again positively influencing QOL (b A1 and b A2). &ese impact their QOL via an indirect approach to improving findings are both explicable and meaningful. One possible positive emotions (benefit finding) and relieving negative explanation may because benefit finding is by far the most emotions (psychological distress) in CP-FC dyads. &e commonly reported kind of meaning-focused coping [10]. significant or borderline total IEs findings using the bias- On the contrary, the results of the negative partner effects corrected bootstrap method further support the mediation of self-efficacy on benefit finding (a P2), and benefit effects of positive (benefit finding) and negative (psycho- finding on QOL (bP1 and bP2) were unexpected. &e logical distress) emotions on the impact of dyads’ self- reason is that all of the above unexpected negative partner effects, including a P2, bP1, bP2, c’P1, and c’P2, may efficacy on their QOL. In both model a and model b, the overall significant partially lie in the interdependence of active coping be- positive c’ actoreffects (sevenout of eight intwo models) of tween CPs and FCs [9]. &e scenario may be as follows: self-efficacy on QOL, correspond relatively well to another overdone active coping in one partner, e.g., FC caregiving, study,inwhicheachperson’s(advancedCPsand theirFCs) may lead to less active coping in the other, e.g., the CP’s self-efficacy positively influenced their own mental and own coping. &erefore, this contradiction in the in- physical health [14]. However, the overall negative c’ terdependence between CP and FC dyads may contribute partner effects (seven out of eight in two models) of self- to the generallynegative impact ofFC coping (self-efficacy efficacy on QOL, although not statistically significant, were and/or benefit finding) on CP’s QOL and/or benefit finding, and vice versa. &e evidence of a positive unanticipated. Journal of Oncology 7 Table 5: &e bios-corrected bootstrap tests of the total effects, total indirect effects, and direct effects for cancer patients and family caregivers . Submodel MCS Submodel PCS Effect Estimate 95% CI low 95% CI high P value Estimate 95% CI low 95% CI high P value 5(a): effects on QOL mediated by BF (model a) CP actor effect Total effect 0.149 0.112 0.192 0.001 0.091 0.053 0.133 0.001 Total IEs 0.005 −0.009 0.021 0.452 0.003 −0.012 0.019 0.645 Direct effect c’ 0.144 0.104 0.191 0.001 0.088 0.046 0.131 0.001 FC actor effect Total effect 0.125 0.087 0.157 0.001 0.122 0.079 0.165 0.001 Total IEs 0.020 0.000 0.040 0.051 0.008 −0.012 0.028 0.429 Direct effect c’ 0.105 0.065 0.141 0.001 0.114 0.069 0.159 0.001 CP partner effect Total effect −0.022 −0.063 0.017 0.251 −0.023 −0.066 0.025 0.374 Total IEs −0.015 −0.034 0.001 0.066 0.005 −0.014 0.025 0.646 Direct effect c’ −0.007 −0.051 0.037 0.769 −0.027 −0.074 0.025 0.311 FC partner effect Total effect 0.019 −0.013 0.050 0.256 −0.012 −0.048 0.024 0.462 Total IEs −0.003 −0.017 0.011 0.635 0.013 0.000 0.028 0.056 Direct effect c’ 0.022 −0.012 0.056 0.190 −0.025 −0.063 0.014 0.170 5(b): effects on QOL mediated by PD (model b) CP actor effect Total effect 0.149 0.112 0.192 0.001 0.091 0.053 0.133 0.001 Total IEs 0.098 0.072 0.129 0.001 0.073 0.051 0.105 0.001 Direct effect c’ 0.051 0.013 0.090 0.011 0.018 −0.029 0.064 0.455 FC actor effect Total effect 0.125 0.087 0.157 0.001 0.122 0.079 0.165 0.001 Total IEs 0.069 0.046 0.095 0.001 0.051 0.032 0.075 0.001 Direct effect c’ 0.056 0.021 0.089 0.004 0.071 0.029 0.113 0.001 CP partner effect Total effect −0.022 −0.063 0.017 0.251 −0.023 −0.066 0.025 0.374 Total IEs 0.005 −0.020 0.026 0.730 0.008 −0.017 0.030 0.520 Direct effect c’ −0.027 −0.068 0.013 0.184 −0.031 −0.076 0.018 0.221 FC partner effect Total effect 0.019 −0.013 0.050 0.256 −0.012 −0.048 0.024 0.462 Total IEs 0.032 0.007 0.057 0.012 0.021 −0.002 0.047 0.078 Direct effect c’ −0.013 −0.048 0.018 0.416 −0.033 −0.070 0.005 0.079 5(c): total IEs on anxiety and depression (model b) CP actor effect Anxiety −0.104 −0.123 −0.084 0.001 −0.101 −0.121 −0.080 0.001 Depression −0.112 −0.133 −0.091 0.001 −0.114 −0.135 −0.093 0.001 FC actor effect Anxiety −0.071 −0.090 −0.051 0.001 −0.072 −0.090 −0.053 0.001 Depression −0.076 −0.099 −0.052 0.001 −0.081 −0.103 −0.056 0.001 CP partner effect Anxiety 0.007 −0.014 0.028 0.476 0.006 −0.014 0.026 0.537 Depression 0.007 −0.014 0.029 0.470 0.007 −0.016 0.029 0.543 FC partner effect Anxiety −0.020 −0.037 −0.002 0.036 −0.017 −0.035 0.002 0.068 Depression −0.021 −0.039 −0.002 0.038 −0.019 −0.038 0.002 0.071 Note: BF �benefit finding; CI �confidence interval; CP �cancer patients; FC �family caregivers; IEs �indirect effects; MCS �mental component summary; PCS �physical component summary; PD �psychological distress. &e bootstrap estimates presented here are based on 2,000 bootstrap samples. direction in the CP partner effect (a P1) of FC self-efficacy benefit finding, anxiety, depression, and QOL in CP-FC on CP psychological distress in model b (part (b) in dyads, and particularly, how to improve the positive in- Table 4) may also support the above perspective on the terdependence of dyadic active coping by CP-FC dyads, is interdependence of active coping in CP-FC dyads. Nev- required. ertheless, this is a reminder that further in-depth ex- In addition, due to the positive coping property of self- ploration, to advance a profound understanding of the efficacy in stressful events, discoveries of the negative total complex dyadic interdependence in terms of self-efficacy, IEs of self-efficacy on anxiety and depression (part (c) in 8 Journal of Oncology Table 5), e.g., CP actor effects, and FC actor/partner effects, Authors’ Contributions are rational. However, the positive CP partner effects, al- Qian Cao, Jiali Gong, and Meizhen Chen were involved in though not statistically significant, are again surprising. &is the study conception/design, literature search/analysis, and may partly result from the above-described mechanism in drafting of the manuscript. Yi Lin was responsible for the dyadic interdependence of active coping by CP-FC dyads. literature search/analysis and drafting of the manuscript. Nevertheless, these findings may further support the study Qiuping Li was responsible for the supervision and critical hypothesis, that self-efficacy may influence QOL by way of revisions of important intellectual content. Qian Cao, Jiali an indirect tactic to relieve negative emotions (psychological Gong, Yi Lin and Meizhen Chen contributed equally to distress) in CP-FC dyads. this work. 4.4. Limitations. First, the cross-sectional survey study re- Acknowledgments stricts the probability of providing outcome variables’ progress trajectory. Second, participants’ unique cultural &e authors thank all patient-family caregiver dyads who background, e.g., Chinese CP-FC dyads, limits the gener- participated in this study and share their experiences. Fi- alization of the study findings to other populations with nancial support for this study was provided by the National diverse cultural backgrounds. Future longitudinal studies Natural Science Foundation of China (nos. 82172844 and targeting participants in dissimilar cultures are required. 81773297). Supplementary Materials 4.5. Implications for Practice. Notwithstanding the afore- mentioned limitations, the findings may point to the fol- Figure S1: theoretical model in testing the impact of self- lowing prospective implications for practice. &e dyadic efficacyonQualityoflifemediatedbyBenefitfinding(Model interdependence of related variables in CP-FC dyads a); Figure S2: theoretical model in testing the impact of self- highlights the importance, for healthcare professionals in efficacy on Quality of life mediated by Psychological distress cancer practice, of treating CP-FC dyads as a coping unit. (Model b); Figure S3: two submodels for testing the impact &e APIMeM findings on the influences of self-efficacy on of self-efficacy on Quality of life mediated by Benefit finding QOL further advance the significant recognition of the (Modela);FigureS4:twosubmodelsfortestingtheimpactof importance of refining dyadic self-efficacy in future in- self-efficacy on Quality of life mediated by Psychological tervention studies aimed at improving CP-FC dyad QOL. In distress (Model b). (Supplementary Materials) caring for CP-FC dyads, dyadic-based interventions, com- prised of such elements as refining dyads’ self-efficacy and cultivating positive dyadic active coping interrelationships, References are highly recommended for improving dyads’ QOL. [1] K. R. Ellis, M. R. Janevic, T. Kershaw, C. H. Caldwell, N. K. Janz, and L. Northouse, “&e influence of dyadic 5. 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