Nurse Media Journal of Nursing
e-ISSN: 2406-8799, p-ISSN: 2087-7811
https://medianers.undip.ac.id
13(3):263-273, December 2023
https://doi.org/10.14710/nmjn.v13i3.54738
ORIGINAL RESEARCH

Determinants of Physical and Mental Healthrelated Quality of Life among Patients with Breast
Cancer During COVID-19 Pandemic
Mohd Jamil1, Leni Merdawati2, Boby Febri Krisdianto2, Daan Khambri3, Wirsma Arif Harahap3,
Hidayat Arifin4,5
1Department of Community Health and Family Nursing, Faculty of Nursing, Universitas Andalas,

Padang, Indonesia
2Department of Medical-Surgical Nursing, Faculty of Nursing, Universitas Andalas, Padang, Indonesia
3Department of Surgery, Faculty of Medicine, Universitas Andalas, Padang, Indonesia
4School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
5Department of Basic Nursing Care, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia

Article Info

Abstract

Article History:
Received: 27 May 2023
Revised: 24 December 2023
Accepted: 25 December 2023
Online: 31 December 2023
Keywords:
Anxiety; breast cancer; COVID-19;
depression; quality of life
Corresponding Author:
Leni Merdawati
Department of Medical-Surgical
Nursing, Faculty of Nursing,
Universitas Andalas, Padang,
Indonesia
Email:
lenimerdawati@nrs.unand.ac.id

Background: The concern surrounding the physical and mental health-related
quality of life (HRQoL) among patients with breast cancer emerged during COVID19. However, there is a lack of sufficient studies that have specifically addressed this
issue. It is crucial to emphasize the evaluation of this aspect as it significantly
impacts the enhancement of future physical and mental HRQoL for these patients.
Purpose: This study investigated the determinants of physical and mental HRQoL
among patients with breast cancer during COVID-19.
Methods: In a cross-sectional study conducted between September and October
2022, participation involved 260 patients diagnosed with breast cancer, selected
through convenience sampling. Our observation focused on assessing the outcomes
of physical and mental HRQoL using the Short Form (SF-12) questionnaire for data
collection. Additionally, the data underwent analysis via binary logistic regression.
Results: Respondents aged <50 years (p=0.010; aOR=2.08; 95% CI=1.18–3.67),
unemployed (p=0.022; aOR=2.29; 95% CI=1.16–4.53), and had high depression
(p=0.026; aOR=2.41; 95% CI=1.13–5.12) have a more likelihood to have low
physical HRQoL. In addition, unemployed respondents (p=<0.001; aOR=4.15; 95%
CI=2.14–8.04) and had high anxiety (p=0.004; aOR=2.71; 95% CI=1.38–5.33) have
more likelihood to have low mental HRQoL.
Conclusion: In this study, it was found that anxiety, depression, and unemployed
respondents were associated with a higher likelihood of experiencing lower physical
and mental HRQoL. Nurses and healthcare workers should prioritize addressing
psychological issues such as anxiety and depression among breast cancer patients,
emphasizing the necessity for interventions aimed at alleviating these concerns.

How to cite: Jamil, M., Merdawati, L., Krisdianto, B. F., Khambri, D., Harahap, W. A., & Arifin, H. (2023).
Determinants of physical and mental health-related quality of life among patients with breast cancer during COVID19 pandemic. Nurse Media Journal of Nursing, 13(3), 263-273. https://doi.org/10.14710/nmjn.v13i3.54738

1.

Introduction
Acute respiratory distress syndrome is an outbreak of Coronavirus disease (COVID-19). The
outbreak of the COVID-19 epidemic that began in December 2019 had a moderately severe impact
and became the most critical and widespread pandemic of this century (Huang et al., 2020).
COVID-19 spreads rapidly in the larger community, including patients with a clinical presentation
of acute respiratory distress syndrome, and causes high morbidity and mortality (Hasan et al.,
2020). The condition of COVID-19 leads to fear and anxiety that impact physical and mental
health-related quality of life (HRQoL) (Shafran et al., 2021). Physical and mental health are
integral components of an individual’s overall quality of life. Physical health encompasses the
state of the body, including aspects such as fitness, freedom from illness, mobility, and the ability
to perform daily tasks without hindrance. On the other hand, mental health encompasses
emotional, psychological, and cognitive well-being, influencing factors like emotional stability,
coping mechanisms, interpersonal relationships, and adaptability to life’s challenges. Both
physical and mental health play pivotal roles in determining an individual’s well-being and ability
to lead a fulfilling and satisfying life (Folsom et al., 2009).
Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 13(3), 2023, 264
Breast cancer patients experience immunosuppression caused by cancer treatments, such as
chemotherapy and other therapies. Decreased immunity puts them in a group that is more at risk
of contracting the virus and suffering from complications of COVID-19 compared to the general
population (Al-Quteimat & Amer, 2020; Al‐Shamsi et al., 2020). During the COVID-19 pandemic,
patients with breast cancer experienced severe mental disorders such as fear of being infected
with COVID-19 during the chemotherapy process and even death (Erdoğan et al., 2022; Hikmat
et al., 2022; Stanizzo et al., 2022). This condition also has an impact on physical condition and
causes weakness (Yang et al., 2021). With conditions that continue to decline, this can have an
impact on the quality of life of patients with breast cancer.
Patients with malignancy experience high levels of psychological distress. Fear of COVID-19
combined with interference with some treatment programs can affect the psychological health of
cancer patients (Momenimovahed & Salehiniya, 2021). The COVID-19 pandemic has had an
emotional impact, and previous research has shown that breast cancer survivors also feel
emotional distress, such as exaggerated anxiety and depression related to a higher level of
ruminative response and chronic worry (Choobin et al., 2021). The most commonly reported
stressor was a higher level of concern regarding the experienced anxiety and depressive symptoms
and a higher fear of cancer recurrence (Massicotte et al., 2021). The previous review studies have
only evaluated the quality of life in general, not specific to physical and mental HRQoL, and not
during the COVID-19 pandemic (Heidary et al., 2023; Mokhtari-Hessari & Montazeri, 2020; Yan
et al., 2016). Thus, this original study aimed to investigate the determinants and analyze their
correlation to physical and mental HRQoL among patients with breast cancer during the COVID19 pandemic.
2. Methods
2.1 Research design
A cross-sectional study was designed to investigate the correlation between independent and
dependent variables (Arifin et al., 2022). The study’s reporting followed the guidelines outlined
in the Strengthening the Reporting of Observational Studies (STROBE) framework for crosssectional studies (Von Elm et al., 2007).
2.2 Setting and samples
The study was conducted from September to October 2022 at a government hospital and a
university hospital in Padang, Indonesia. Both study locations were elected as a referral hospitals
for cancer treatment in Padang. A total of 260 respondents were recruited using convenience
sampling. The sample size is measured by G*Power analysis statistical app with α=0.05, β=0.20,
and effect size of 0.26 (medium effect size). Finally, the minimum sample size was 190-260
participants obtained based on the analysis (Cohen, 2013; Hohls et al., 2021). During the study
process, no dropout respondents were found. All of the respondents met the criteria of 1) being
female aged 18-60 years, 2) being diagnosed with breast cancer for at least six months, 3) having
been during or undergoing chemotherapy and radiology, 4) communicating in the local language
(Padang) and Indonesia language, 5) and having the commitment to participate in this study. In
addition, respondents with cognitive impairment or psychiatric disorders (e.g., schizophrenia,
psychosis, and depression) before the breast cancer diagnosis, were excluded from this study.
2.3 Measurement and data collection
The independent variables in this study included demographical data (age, marital status,
educational level, and employment status), disease characteristics (cancer stages, cancer
treatment, and disease duration), anxiety, and depression. Moreover, the dependent variables
were physical and mental HRQoL. The general information sheet was designed to gather data on
demographic and disease characteristics, encompassing details such as age, marital status,
education level, number of children, employment status, cancer stages, cancer treatment, and
disease duration.
Anxiety and depression were measured using the Hospital Anxiety and Depression Scale
(HADS), consisting of seven items for depression and seven for anxiety (Zigmond & Snaith, 1983).
Each item is rated on a four-point Likert scale (0 = not at all, to 3 = most of the time). The total
score ranged from 0 to 21, indicating low anxiety and depression (0-7) and high anxiety and
depression (8-21) (Zigmond & Snaith, 1983). The HADS-Indonesian version scale showed
Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 13(3), 2023, 265
acceptable internal reliability with a Cronbach’s alpha of 0.85 for anxiety and 0.80 for depression,
with the Kaiser-Meyer-Olkin statistics of 0.89 and Bartlett’s test of sphericity (χ2 (91, N=200) of
1052.38, p<0.001 (Tiksnadi et al., 2023).
Physical and mental HRQoL was measured using the short form (SF-12) with 12-items and
calculated following the scoring algorithm developed by Ware et al. (1996). SF-12 measures
consist of two concepts, including Physical Component Summary (PCS-12) and Mental
Component Summary (MCS-12). SF-12 consists of two components; first, the PCS-12 score is
represented by six items: 1) general health with response categories excellent/very good/good/
fair, 2) moderate activities, 3) climb several flights of stairs with response category limited a lot/
limited/not limited at all, 4) accomplish less (physical), 5) limited in kind of work with response
category all of the time/most of the time/a little of the time/none of the time, and 6) pain
interference with response category not at all/a little bit/moderate/quite a bit/extremely. Second,
MCS-12 is represented by six items: accomplish less (emotional), did work less carefully, calm and
peaceful, energy or vitality, downhearted and blue, and social limitations. All items MCS-12 with
response: all of the time/most of the time/a little of the time/none of the time. The PCS-12 and
MCS-12 scores were computed and normalized for SF-12v2 according to published algorithms
(Ware et al., 1996). Scores range from 0 to 100, with a higher score indicating better physical and
mental health functioning. A score of 50 or less on the PCS-12 could be considered low physical
functioning, while a score of 42 or less on the MCS-12 may be indicative of low mental health
functioning (Soh et al., 2021; Ware et al., 1995). The SF-12 version 2 showed good internal
reliability for PCS-12 with Cronbach’s alpha of 0.83 for anxiety and 0.81 for MCS-12 (Soh et al.,
2021).
The data collection process commenced after obtaining permission from the concerned
hospitals, adhering to ethical guidelines. The primary method employed for data acquisition
involved the administration of a structured questionnaire. To facilitate this process, the
researcher, with the aid of a research assistant, conducted the data collection. The researcher and
the assistant worked collaboratively, accompanying respondents throughout the questionnaire
completion. This approach ensured a supportive environment, enabling respondents to address
any queries or concerns they encountered while filling out the questionnaire. By maintaining a
supportive presence, the researcher aimed to enhance respondent comfort and accuracy in
providing necessary information for the study.
2.4 Data analysis
The data analysis was performed using IBM SPSS 22.0 software. Descriptive statistics
comprised frequencies and percentages for categorical variables and mean and standard
deviation (SD) for continuous variables. A Chi-squared test was used to examine the correlations
between demographic characteristics and disease characteristics, anxiety, depression, and
physical and mental HRQoL. The variables with a p-value of ≤ 0.20 in the Chi-squared test were
further entered into the univariate logistic regression analysis to examine the association of these
influential factors with physical and mental HRQoL (Mickey & Greenland, 1989). A multivariate
logistic regression model was used to identify the significant predictors of the quality of life of
breast cancer survivors after adjusting for confounding variables in the univariate logistic
regression model (p<0.05). All tests were two-tailed, with p-values less than 0.05 were considered
statistically significant.
2.5 Ethical considerations
This study has been deemed ethically appropriate by the Health Research Ethics Committee
of Dr. M. Djamil Hospital Padang, Indonesia (No. L.B.02.02/5.7/410/2022), in accordance with
seven WHO 2011 standards. All study participants received a consent form describing the study’s
aim and providing adequate information for them to make an informed decision about their
participation. Those participants willing to participate had to sign the form before completing the
questionnaire, and participation was voluntary without any coercion.
3. Results
3.1 Demographics and disease characteristics of the respondents
In total, 260 eligible breast cancer survivors participated in this study. More than half of
respondents (62.7%) were younger, with a mean age of 47.14 years (range, 18-60 years). Most
Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 13(3), 2023, 266
respondents were married (81.2%) and had a high education level (80.8%). Regarding the number
of children, more than half (67.3%) of participants had ≤ 3 children and were unemployed
(54.0%). According to the cancer characteristics, more than half of the participants were
diagnosed in III or IV stages, and the majority received 2-3 treatments. Overall, the mean of the
disease duration is 34.26 months. Furthermore, more than 50% had high anxiety, and less than
70% had low depression. From this study, more than half of respondents had low physical and
mental health functioning related to quality of life (Table 1).
Table 1. Characteristics of respondents (n=260)
Variables
Age (years)
Younger (≤50 years old)
Older (>50 years old)
Marital status
Married
Widowed/Others
Education level
Low
High
Number of children
≤3
>3
Employment status
Employed
Unemployed
Cancer stages
I and II
III and IV
Cancer treatment
1 treatment†
2-3 treatment‡
Disease duration (months)
≤24 months
>24months
Anxiety
Low anxiety
High anxiety
Depression
Low depression
High depression
Physical health functioning
Low
High
Mental health functioning
Low
High

M(SD)
47.14(7.37)

34.26(26.91)
7.48(4.22)
5.67(3.80)
42.88(7.34)

n

%

163
97

62.7
37.3

211
49

81.2
18.8

50
210

19.2
80.8

175
85

67.3
32.7

105
155

40.4
59.6

118
142

45.4
54.6

37
222

14.3
85.7

145
115

55.8
44.2

123
137

47.3
52.7

192
68

73.8
26.2

139
121

53.5
46.5

134
126

51.5
48.5

42.53(10.93)

Notes:

† Surgery, chemotherapy, radiotherapy; ‡Surgery and, or chemotherapy and radiotherapy and others

M: Mean; SD: standard deviation

3.2 The correlation of demographic and disease characteristics, anxiety, and depression with
physical and mental HRQoL
Table 2 shows the bivariate analysis of physical and mental HRQoL. In the physical HRQoL,
age, number of children, employment status, cancer stages, anxiety, and depression showed a
significant relationship with physical HRQoL (p<0.05). Moreover, number of children,
employment status, anxiety and depression had a significant correlation with mental HRQoL
(p<0.05). Furthermore, the variables with p<0.20 were included in the multivariate analysis.

Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 13(3), 2023, 267
Table 2. The correlations of demography, disease characteristics, anxiety, depression, physical,
with mental health-related quality of life (n=260)
Physical
High
Low
f (%)
f (%)

Variables
Age (years)
Younger (≤50)
Older (>50)
Marital status
Married
Widowed/Others
Education level
High
Low
Number of children
≤3
>3
Employment status
Employed
Unemployed
Cancer stages
I and II
III and IV
Cancer treatment
1 treatment†
2-3 treatment‡
Disease duration
(months)
≤24 months
>24months
Anxiety
Low anxiety
High anxiety
Depression
Low depression
High depression

Mental
X2

p

High
f (%)

Low
f (%)

X2

p

69 (39.3)
57 (58.8)

99 (60.7)
40 (41.2)

9.29

0.002

76 (46.6)
50 (51.5)

87 (41.9)
47 (48.5)

0.59

0.443

98 (46.3)
23 (46.9)

113 (53.6)
26 (53.1)

0.00

0.950

99 (46.9)
27 (55.1)

112 (53.1)
22 (44.9)

1.06

0.302

103 (49.0)
18 (36.0)

107 (51.0)
32 (64.0)

2.76

0.096

105 (50.0)
21 (42.0)

105 (50.0)
29 (58.0)

1.035

0.309

70 (40.0)
51 (60.0)

105 (60.0)

9.19

0.002

67 (38.3)
59 (69.4)

108 (61.7)
26 (30.6)

22.19

<0.001

70 (66.7)
51 (32.9)

35 (33.3)
104 (67.1)

28.68 <0.001

80 (76.2)
46 (29.7)

25 (23.8)
109 (70.3)

54.22

<0.001

65 (55.1)
56 (39.4)

53 (44.9)
86 (60.6)

6.43

0.012

62 (52.5)
64 (45.1)

56 (47.5)
78 (54.9)

1.44

0.230

18 (48.6)
102 (45.9)

19 (51.4)
120 (54.1)

0.93

0.760

16 (43.2)
109 (49.1)

21 (56.8)
113 (50.9)

0.43

0.509

66 (45.5)
55 (47.8)

79 (54.5)
60 (52.2)

0.13

0.711

67 (46.2)
59 (51.3)

78 (53.8)
56 (48.7)

0.66

0.414

78 (63.4)
43 (31.4)

45 (36.6)
94 (68.6)

26.72

<0.001

84 (68.3)
42 (30.7)

39 (31.7)
95 (69.3)

36.75

<0.001

107 55.7)
14 (20.6)

85 (44.3)
54 (79.4)

24.92 <0.001

104 (54.2)
22 (32.4)

88 (45.8)
46 (67.6)

9.56

0.002

34 (40.0)

3.3 Determinants of physical and mental HRQoL
Based on the multivariate analysis using binary logistic regression, respondents with younger
age had 2.08 times more likely to have low physical health compared to older age (p-value: 0.010;
aOR:2.08; 95% CI:1.18-3.67). Based on work status, respondents who did not work (unemployed)
had 2.29 times greater to have low physical health rather than employed (p-value: 0.022; aOR:
2.29; 95% CI: 1.16-4.53). In addition, respondents with high depression had 2.41 times greater to
have low physical health compared to low depression (p-value: 0.026; aOR: 2.41; 95% CI: 1.135.12). According to mental HRQoL, unemployed respondents had 4.15 times more likely to have
low mental health compared to employed respondents (p-value: <0.001; aOR: 4.15; 95% CI: 2.148.04). Furthermore, respondents with high anxiety had 2.71 times greater to have low mental
health compared to respondents with low anxiety (p-value: 0.004; aOR: 2.71; 95% CI: 1.38-5.33)
(Table 3).
4. Discussion
Physical and mental health-related quality of life (HRQoL) becomes a critical concern for
patients with breast cancer. This study explored the determinants affecting physical and mental
HRQoL from the perspectives of demographics and physiological symptoms such as anxiety and
depression. The correlation between age, employment status, and depression is discussed
concerning physical HRQoL. Additionally, work status and anxiety are examined in relation to
mental HRQoL.

Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 13(3), 2023, 268
Table 3. Multivariate analysis of physical and mental health–related quality of life
Physical health

Variables
Age
Older (>50 years old)
Younger (≤50 years old)
Level of education
High
Low
Number of children
>3
≤3
Work status
Employed
Unemployed
Cancer stages
I and II
III and IV
Anxiety
Low
High
Depression
Low
High

Mental health

aOR

(95% CI)

p-value

aOR

(95% CI)

p-value

Ref.
2.08**

(1.18 – 3.67)

0.010

NA
NA

NA

NA

Ref.
1.03

(0.26 – 4.00)

0.966

NA
NA

NA

NA

Ref.
1.16

(0.61 – 1.18)

0.750

Ref.
1.87*

(0.98 – 3.57)

0.057

Ref.
2.29**

(1.16 – 4.53)

0.022

Ref.
4.15***

(2.14 – 8.04)

<0.001

Ref.
1.65

(0.94 – 2.89)

0.083

NA
NA

NA

NA

Ref.
1.73

(0.89 – 3.33)

0.096

Ref.
2.71***

(1.38 – 5.33)

0.004

Ref.
2.41**

(1.13 – 5.12)

0.026

Ref.
0.79

(0.37 – 1.65)

0.533

Notes:
*p<0.1; **p<0.05; ***p<0.01

4.1 Physical HRQoL
In this study, respondents aged < 50 years were more likely to have low physical HRQoL.
Physical activity is a crucial for better quality of life and ageing in the long-term care. This finding
is contradicted with a previous study which stated that people aged < 50 years had better physical
HRQoL (Jang et al., 2019). Studies stated that engaging in regular physical exercise significantly
enhances individuals’ physical HRQoL (Gill et al., 2013; Marquez et al., 2020; Wei et al., 2022).
Low physical HRQoL at aged < 50 years can be influenced by disease and other risk behaviors,
such as smoking and drinking that make it unable to carry out physical activities properly (Megari,
2013; Nari et al., 2021; Tran et al., 2022). However, this study is still limited to several variables,
such as lifestyle, which might be associated with the low physical HRQoL in population aged < 50
years. Therefore, the addition of variables to the future studies is highly recommended.
In addition, respondents who were unemployed had more likely to have low physical HRQoL.
Unemployment in cancer patients is correlated with increased financial burden, increased costs
of living, and ongoing treatment (Mols et al., 2020). In addition, people who are working will have
more physical activity, so they can increase their physical strength, and vice versa for people who
are unemployed (Schutgens et al., 2009). However, a significant aspect during the COVID-19
pandemic is the situation where parents must manage both childcare and homeschooling
(Vogelbacher); this situation can potentially impact physical HRQoL (Galanti et al., 2021;
Tavares, 2017). In addition, with these conditions, it is widely reported that people experience
increased stress, malnutrition characterized by increased body weight, and decreased physical
HRQoL (Alshahrani et al., 2022; Majumdar et al., 2020; Muñoz-Corona et al., 2022).
Furthermore, this study also showed that respondents with high depression had more likely
to have low physical HRQoL. This finding is similar with the previous studies (Cho et al., 2019;
Fernandes et al., 2021; Hohls et al., 2021). The condition of the COVID-19 pandemic is an added
burden that can induce depression among breast cancer patients. Moreover, this circumstance is
compounded by uncertainties regarding recovery and the necessity for regular treatments like
chemotherapy and/or radiation therapy (de Souza et al., 2014). Also, depressive conditions can
exacerbate the severity of symptoms for people dealing with breast cancer (Wondimagegnehu et
al., 2019). This has an impact on the immune system and physical conditions that can get weaker

Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 13(3), 2023, 269
(Wang et al., 2020). For this reason, it is very important to treat depression in patients with breast
cancer, especially during the COVID-19 pandemic.
4.2 Mental HRQoL
Regarding the mental HRQoL, unemployed respondents were more likely to have low mental
HRQoL. Patients with breast cancer who have no activity or low social relationships can cause a
decrease in low mental health (Yang et al., 2022). Previous studies indicated that breast cancer
patients experiencing stable physical health and engaged in work tend to exhibit higher mental
HRQoL (Carreira et al., 2018; Jin, 2022). This correlation might be attributed to the supportive
environment fostered by colleagues and the potential diversion of the patient’s focus away from
their illness (Finck et al., 2018). Consequently, it is suggested that breast cancer patients in
favorable physical health conditions can actively engage in physical activities, maintain
productivity, and cultivate strong social relationships, which can contribute positively to both
their physical and mental quality of life. This recommendation emphasizes the potential benefits
derived from staying physically active and socially engaged despite the challenges posed by the
illness.
Patients with breast cancer experienced anxiety related to cancer treatments, fear of cancer
recurrence and fear about uncertainties surrounding life and death (Baqutayan, 2012; Tiedtke et
al., 2012). In addition, cancer patients also have anxiety regarding postponed appointments,
delayed treatments, and limited access to medical facilities due to COVID-19 pandemic (Rucinska
& Nawrocki, 2022) . Furthermore, cancer patients are vulnerable to COVID-19 infecttion and had
60% increased risk of positive COVID-19 test compard with individual without cancer (Lee et al.,
2021). These collective stressor may contributes to anxiety among patients with breast cancer,
impacting their mental HRQoL. Therefore, it can make the healing process of the disease take
longer (Carreira et al., 2018). Prior investigations have demonstrated a notable increase in anxiety
levels among breast cancer patients amid the COVID-19 pandemic (Bartmann et al., 2021; Shah
et al.; Stanizzo et al., 2022; Yasin et al., 2021). This surge in anxiety can be attributed to the fear
associated with potential COVID-19 infection, intensifying concerns about the worsening of their
existing medical condition and the heightened risk of mortality. Consequently, this finding places
an augmented responsibility on nurses. Beyond addressing the complexities of cancer treatment,
nurses are now compelled to provide interventions aimed at alleviating anxiety among breast
cancer patients. Effective mental health management becomes crucial, encompassing strategies
to regulate stress, depression, and anxiety levels. These interventions are essential to mitigate the
amplified psychological distress experienced by breast cancer patients, thereby enhancing their
overall well-being and coping mechanisms during this challenging period characterized by the
pandemic.
5.

Implications and limitations
In the context of the COVID-19 pandemic, understanding the nuances HRQoL among breast
cancer patients has never been more critical. Our research underscores the profound role
healthcare professionals play in shaping the QOL of these patients. During global crises, such as
pandemics, external factors might exacerbate the mental and physical health challenges faced by
breast cancer patients. Nurses should recognize the heightened challenges faced by breast cancer
patients during crises like the COVID-19 pandemic and offer personalized care and interventions
that address both physical and mental health concerns. This brings to the fore the crucial
importance of tailored clinical interventions. Furthermore, our findings illuminate the necessity
for systemic changes. Policymakers, armed with this knowledge, can champion reforms that
embrace specialized care models during such crises.
This study offers empirical evidence to identify the determinants of physical and mental
HRQoL among patients with breast cancer during the COVID-19 pandemic. However, several
limitations should be considered. Firstly, the confirmation of causal relationships between risk
factors and physical and mental health-related quality of life was hindered by the cross-sectional
study design. Secondly, the limited generalizability of their findings arose from recruiting all
participants solely from two hospitals within one province of Indonesia. Thirdly, the exclusion of
other risk factors such as chronic diseases, health behaviors, and lifestyle factors from the study
should be noted.
Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 13(3), 2023, 270
6. Conclusion
Physical and mental HRQoL aspects among breast cancer patients shows a substantial
correlation with various demographic and psychological factors, including age and employment
status, as well as anxiety and depression levels. This study revealed a clear association indicating
that higher levels of anxiety and depression significantly increase the likelihood of experiencing
lower physical and mental HRQoL. This underscores the critical need for targeted interventions
aimed at reducing anxiety and depression specifically tailored for breast cancer patients.
Initiating such interventions becomes pivotal in addressing the challenges posed by these
psychological factors, thereby potentially enhancing the overall quality of life experienced by
individuals grappling with breast cancer. Recognizing the impact of anxiety and depression on
the QoL of breast cancer patients and implementing targeted strategies such as psychological
intervention to mitigate these psychological challenges stands as a vital step in improving the
well-being and coping mechanisms of these individuals.
Acknowledgment
We would like to thank all the patients with breast cancer, physicians and nurses who
participated in this study.
Author contribution
Conceptualization: Mohd Jamil, Leni Merdawati, Daan Khambri
Data curation: Wirsma Arif, Harahap,
Formal analysis: Leni Merdawati, Boby Febri Krisdianto
Validation: Daan Khambri, Leni Merdawati
Visualization: Mohd Jamil, Boby Febri Krisdianto
Writing original draft: Mohd Jamil, Leni Merdawati, Hidayat Arifin
Writing-review & editing: Leni Merdawati, Hidayat Arifin
Conflict of interest
None
References
Al-Quteimat, O. M., & Amer, A. M. (2020). The impact of the COVID-19 pandemic on cancer
patients.
American
Journal
of
Clinical
Oncology,
43(6),
452-455.
https://doi.org/10.1097/COC.0000000000000712
Al‐Shamsi, H. O., Alhazzani, W., Alhuraiji, A., Coomes, E. A., Chemaly, R. F., Almuhanna, M.,
Wolff, R. A., Ibrahim, N. K., Chua, M. L., & Hotte, S. J. (2020). A practical approach to the
management of cancer patients during the novel coronavirus disease 2019 (COVID‐19)
pandemic: An international collaborative group. The Oncologist, 25(6), e936-e945.
https://doi.org/10.1634/theoncologist.2020-0213
Alshahrani, S. M., Alghannam, A. F., Taha, N., Alqahtani, S. S., Al-Mutairi, A., Al-Saud, N., &
Alghnam, S. (2022). The Impact of COVID-19 pandemic on weight and body mass index in
Saudi Arabia: A longitudinal study. Frontiers in Public Health, 9, 775022.
https://doi.org/10.3389/fpubh.2021.775022
Arifin, H., Ibrahim, K., Rahayuwati, L., Herliani, Y. K., Kurniawati, Y., Pradipta, R. O., Sari, G. M.,
Ko, N.-Y., & Wiratama, B. S. (2022). HIV-related knowledge, information, and their
contribution to stigmatization attitudes among females aged 15–24 years: Regional
disparities in Indonesia. BMC Public Health, 22, 637. https://doi.org/10.1186/s12889-02213046-7
Baqutayan, S. M. (2012). The effect of anxiety on breast cancer patients. Indian Journal of
Psychological Medicine, 34(2), 119-123. https://doi.org/10.4103/0253-7176.101774
Bartmann, C., Fischer, L.-M., Hübner, T., Müller-Reiter, M., Wöckel, A., McNeill, R. V., Schlaiss,
T., Kittel-Schneider, S., Kämmerer, U., & Diessner, J. (2021). The effects of the COVID-19
pandemic on psychological stress in breast cancer patients. BMC Cancer, 21, 1356.
https://doi.org/10.1186/s12885-021-09012-y
Carreira, H., Williams, R., Müller, M., Harewood, R., Stanway, S., & Bhaskaran, K. (2018).
Associations between breast cancer survivorship and adverse mental health outcomes: A
Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 13(3), 2023, 271
systematic review. Journal of the National Cancer Institute, 110(12), 1311-1327.
https://doi.org/10.1093/jnci/djy177
Cho, Y., Lee, J. K., Kim, D.-H., Park, J.-H., Choi, M., Kim, H.-J., Nam, M.-J., Lee, K.-U., Han, K.,
& Park, Y.-G. (2019). Factors associated with quality of life in patients with depression: A
nationwide
population-based
study.
Plos
One,
14(7),
e0219455-e0219455.
https://doi.org/10.1371/journal.pone.0219455
Choobin, M. H., Mirabolfathi, V., Chapman, B., Moradi, A. R., Grunfeld, E. A., & Derakshan, N.
(2021). The impact of COVID-19 outbreak on emotional and cognitive vulnerability in Iranian
women
with
breast
cancer.
Frontiers
in
Psychology,
12,
663310.
https://doi.org/10.3389/fpsyg.2021.663310
Cohen, J. (2013). Statistical power analysis for the behavioral sciences. Routledge.
de Souza, B. F., de Moraes, J. A., Inocenti, A., dos Santos, M. A., Silva, A. E. B. d. C., & Miasso, A.
I. (2014). Women with breast cancer taking chemotherapy: Depression symptoms and
treatment adherence. Revista Latino-Americana de Enfermagem, 22(5), 866-873.
https://doi.org/10.1590/0104-1169.3564.2491
Erdoğan, A. P., Ekinci, F., Acar, Ö., & Göksel, G. (2022). Level of COVID-19 fear in cancer patients.
Middle East Current Psychiatry, 29, 9. https://doi.org/10.1186/s43045-022-00181-5
Fernandes, M. d. S. V., Mendonça, C. R., da Silva, T. M. V., & Noll, M. (2021). The relationship
between depression and quality of life in students and the academic consequences: Protocol
for a systematic review with meta-analysis. International Journal of Educational Research,
109, 101812. https://doi.org/10.1016/j.ijer.2021.101812
Finck, C., Barradas, S., Zenger, M., & Hinz, A. (2018). Quality of life in breast cancer patients:
Associations with optimism and social support. International Journal of Clinical and Health
Psychology, 18(1), 27-34. https://doi.org/10.1016/j.ijchp.2017.11.002
Folsom, D. P., Depp, C., Palmer, B. W., Mausbach, B. T., Golshan, S., Fellows, I., Cardenas, V.,
Patterson, T. L., Kraemer, H. C., & Jeste, D. V. (2009). Physical and mental health-related
quality of life among older people with schizophrenia. Schizophrenia Research, 108(1-3),
207-213. https://doi.org/10.1016/j.schres.2008.12.008
Galanti, T., Guidetti, G., Mazzei, E., Zappalà, S., & Toscano, F. (2021). Work from home during
the COVID-19 outbreak: The impact on employees' remote work productivity, engagement,
and stress. Journal of Occupational and Environmental Medicine, 63(7), e426-e432.
https://doi.org/10.1097/JOM.0000000000002236
Gill, D. L., Hammond, C. C., Reifsteck, E. J., Jehu, C. M., Williams, R. A., Adams, M. M., Lange,
E. H., Becofsky, K., Rodriguez, E., & Shang, Y.-T. (2013). Physical activity and quality of life.
Journal of Preventive Medicine and Public Health, 46(Suppl 1), S28-S34.
https://doi.org/10.3961/jpmph.2013.46.S.S28
Hasan, S. S., Capstick, T., Ahmed, R., Kow, C. S., Mazhar, F., Merchant, H. A., & Zaidi, S. T. R.
(2020). Mortality in COVID-19 patients with acute respiratory distress syndrome and
corticosteroids use: A systematic review and meta-analysis. Expert Review of Respiratory
Medicine, 14(11), 1149-1163.
Heidary, Z., Ghaemi, M., Hossein Rashidi, B., Kohandel Gargari, O., & Montazeri, A. (2023).
Quality of life in breast cancer patients: A systematic review of the qualitative studies. Cancer
Control, 30, 10732748231168318. https://doi.org/10.1177/10732748231168318
Hikmat, R., Rahayu, U., Pebrianti, S., Cahyani, E. M., Sari, C. P., & Afrilia, G. (2022). Postoperative pain management with non-pharmacological interventions in patients undergoing
breast cancer surgery: A systematic scoping review. The Journal of Palembang Nursing
Studies, 1(3), 125-133. https://doi.org/10.55048/jpns.v1i3.24
Hohls, J. K., König, H.-H., Quirke, E., & Hajek, A. (2021). Anxiety, depression and quality of lifeA systematic review of evidence from longitudinal observational studies. International
Journal of Environmental Research and Public Health, 18(22), 12022.
https://doi.org/10.3390/ijerph182212022
Huang, C., Wang, Y., Li, X., Ren, L., Zhao, J., Hu, Y., Zhang, L., Fan, G., Xu, J., & Gu, X. (2020).
Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The
Lancet, 395(10223), 497-506. https://doi.org/10.1016/S0140-6736(20)30183-5
Jang, H. J., Satre, D. D., Leyden, W., Leibowitz, A., & Silverberg, M. J. (2019). Mental and physical
quality of life by age groups in people living with HIV. The Journal of the Association of
Nurses in AIDS Care, 30(5), 500-510. https://doi.org/10.1097/JNC.0000000000000064
Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 13(3), 2023, 272
Jin, J. (2022). Factors associated with the quality of work life among working breast cancer
survivors.
Asia-Pacific
Journal
of
Oncology
Nursing,
9(2),
97-104.
https://doi.org/10.1016/j.apjon.2021.11.005
Lee, K. A., Ma, W., Sikavi, D. R., Drew, D. A., Nguyen, L. H., Bowyer, R. C. E., Cardoso, M. J., Fall,
T., Freidin, M. B., Gomez, M., Graham, M., Guo, C. G., Joshi, A. D., Kwon, S., Lo, C. H.,
Lochlainn, M. N., Menni, C., Murray, B., Mehta, R., . . . Chan, A. T. (2021). Cancer and risk of
COVID-19 through a general community survey. Oncologist, 26(1), e182-185.
https://doi.org/10.1634/theoncologist.2020-0572
Majumdar, P., Biswas, A., & Sahu, S. (2020). COVID-19 pandemic and lockdown: Cause of sleep
disruption, depression, somatic pain, and increased screen exposure of office workers and
students of India. Chronobiology International, 37(8), 1191-1200.
Marquez, D. X., Aguiñaga, S., Vásquez, P. M., Conroy, D. E., Erickson, K. I., Hillman, C., Stillman,
C. M., Ballard, R. M., Sheppard, B. B., Petruzzello, S. J., King, A. C., & Powell, K. E. (2020).
A systematic review of physical activity and quality of life and well-being. Translational
Behavioral Medicine, 10(5), 1098-1109. https://doi.org/10.1093/tbm/ibz198
Massicotte, V., Ivers, H., & Savard, J. (2021). COVID-19 pandemic stressors and psychological
symptoms in breast cancer patients. Current Oncology, 28(1), 294-300.
https://doi.org/10.3390/curroncol28010034
Megari, K. (2013). Quality of life in chronic disease patients. Health Psychology Research, 1(3),
e27-e27. https://doi.org/10.4081/hpr.2013.e27
Mickey, R. M., & Greenland, S. (1989). The impact of confounder selection criteria on effect
estimation. American Journal of Epidemiology, 129(1), 125-137.
Mokhtari-Hessari, P., & Montazeri, A. (2020). Health-related quality of life in breast cancer
patients: Review of reviews from 2008 to 2018. Health and Quality of Life Outcomes, 18,
338. https://doi.org/10.1186/s12955-020-01591-x
Mols, F., Tomalin, B., Pearce, A., Kaambwa, B., & Koczwara, B. (2020). Financial toxicity and
employment status in cancer survivors. A systematic literature review. Support Care Cancer,
28(12), 5693-5708. https://doi.org/10.1007/s00520-020-05719-z
Momenimovahed, Z., & Salehiniya, H. (2021). Delay in the diagnosis of breast cancer during
coronavirus pandemic. EXCLI Journal, 20, 142-144. https://doi.org/10.17179/excli20203318
Muñoz-Corona, C., Gutiérrez-Canales, L. G., Ortiz-Ledesma, C., Martínez-Navarro, L. J., Macías,
A. E., Scavo-Montes, D. A., & Guaní-Guerra, E. (2022). Quality of life and persistence of
COVID-19 symptoms 90 days after hospital discharge. The Journal of International Medical
Research, 50(7), 03000605221110492. https://doi.org/10.1177/03000605221110492
Nari, F., Jeong, W., Jang, B. N., Lee, H. J., & Park, E.-C. (2021). Association between healthy
lifestyle score changes and quality of life and health-related quality of life: A longitudinal
analysis of South Korean panel data. BMJ Open, 11(10), e047933-e047933.
https://doi.org/10.1136/bmjopen-2020-047933
Rucinska, M., & Nawrocki, S. (2022). COVID-19 Pandemic: Impact on cancer patients.
International Journal of Environmental Research and Public Health, 19(19), 12470.
https://doi.org/10.3390/ijerph191912470
Schutgens, C. A. E., Schuring, M., Voorham, T. A. J., & Burdorf, A. (2009). Changes in physical
health among participants in a multidisciplinary health programme for long-term
unemployed persons. BMC Public Health, 9, 197. https://doi.org/10.1186/1471-2458-9-197
Shafran, R., Rachman, S., Whittal, M., Radomsky, A., & Coughtrey, A. (2021). Fear and anxiety in
COVID-19: Preexisting anxiety disorders. Cognitive and Behavioral Practice, 28(4), 459467. https://doi.org/10.1016/j.cbpra.2021.03.003
Shah, Y. B., Kjelstrom, S., Martinez, D., Leitenberger, A., Manasseh, D.-M., Bollmann-Jenkins,
M., Partridge, A., Kaklamani, V., Chlebowski, R., Larson, S., & Weiss, M. (2023). Risk factors
for heightened COVID-19-Related anxiety among breast cancer patients. Cancer Medicine,
12(3), 3577-3588. https://doi.org/10.1002/cam4.5184
Soh, S.-E., Morello, R., Ayton, D., Ahern, S., Scarborough, R., Zammit, C., Brand, M., Stirling, R.
G., & Zalcberg, J. (2021). Measurement properties of the 12-item short form health survey
version 2 in Australians with lung cancer: A Rasch analysis. Health and Quality of Life
Outcomes, 19, 157. https://doi.org/10.1186/s12955-021-01794-w
Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 13(3), 2023, 273
Stanizzo, M. R., Castelli, L., Di Nardo, C., Brunetti, M., De Sanctis, C., & Ghiggia, A. (2022).
Psychological distress in breast cancer patients during the Italian COVID-19 pandemic.
International Journal of Environmental Research and Public Health, 19(18), 11433.
https://doi.org/10.3390/ijerph191811433
Tavares, A. I. (2017). Telework and health effects review. International Journal of Healthcare,
3(2), 30-36.
Tiedtke, C., de Rijk, A., Donceel, P., Christiaens, M. R., & de Casterlé, B. D. (2012). Survived but
feeling vulnerable and insecure: A qualitative study of the mental preparation for RTW after
breast cancer treatment. BMC Public Health, 12, 538. https://doi.org/10.1186/1471-2458-12538
Tiksnadi, B. B., Triani, N., Fihaya, F. Y., Turu' Allo, I. J., Iskandar, S., & Putri, D. A. E. (2023).
Validation of hospital anxiety and depression scale in an Indonesian population: A scale
adaptation study. Family Medicine and Community Health, 11(2), e001775.
https://doi.org/10.1136/fmch-2022-001775
Tran, T. X. M., Lee, S., Oh, C.-M., Chang, Y. J., & Cho, H. (2022). Understanding health problems
in people with extremely low health-related quality of life in Korea. Scientific Reports, 12(1),
4037. https://doi.org/10.1038/s41598-022-07528-2
Von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., & Vandenbroucke, J. P.
(2007). The Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) statement: Guidelines for reporting observational studies. https://www.equatornetwork.org/reporting-guidelines/strobe/
Wang, X., Wang, N., Zhong, L., Wang, S., Zheng, Y., Yang, B., Zhang, J., Lin, Y., & Wang, Z.
(2020). Prognostic value of depression and anxiety on breast cancer recurrence and
mortality: A systematic review and meta-analysis of 282,203 patients. Molecular Psychiatry,
25(12), 3186-3197. https://doi.org/10.1038/s41380-020-00865-6
Ware, J., Jr., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form health survey:
Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3),
220-233. https://doi.org/10.1097/00005650-199603000-00003
Ware, J. E., Keller, S. D., & Kosinski, M. (1995). SF-12: How to score the SF-12 physical and
mental health summary scales. Health Institute, New England Medical Center.
Wei, L., Hu, Y., Tao, Y., Hu, R., & Zhang, L. (2022). The effects of physical exercise on the quality
of life of healthy older adults in China: A systematic review. Frontiers in Psychology, 13,
895373. https://doi.org/10.3389/fpsyg.2022.895373
Wondimagegnehu, A., Abebe, W., Abraha, A., & Teferra, S. (2019). Depression and social support
among breast cancer patients in Addis Ababa, Ethiopia. BMC Cancer, 19, 836.
https://doi.org/10.1186/s12885-019-6007-4
Yan, B., Yang, L.-M., Hao, L.-P., Yang, C., Quan, L., Wang, L.-H., Wu, Z., Li, X.-P., Gao, Y.-T., Sun,
Q., & Yuan, J.-M. (2016). Determinants of quality of life for breast cancer patients in
Shanghai, China. Plos One, 11(4), e0153714. https://doi.org/10.1371/journal.pone.0153714
Yang, L., Chai, P., Yu, J., & Fan, X. (2021). Effects of cancer on patients with COVID-19: A
systematic review and meta-analysis of 63,019 participants. Cancer Biology & Medicine,
18(1), 298-307. https://doi.org/10.20892/j.issn.2095-3941.2020.0559
Yang, Y., Lin, Y., Sikapokoo, G. O., Min, S. H., Caviness-Ashe, N., Zhang, J., Ledbetter, L., &
Nolan, T. S. (2022). Social relationships and their associations with affective symptoms of
women with breast cancer: A scoping review. Plos One, 17(8), e0272649.
https://doi.org/10.1371/journal.pone.0272649
Yasin, A. I., Topcu, A., Shbair, A. T., Isleyen, Z. S., Ozturk, A., Besiroglu, M., & Türk, H. M. (2021).
Anxiety levels of breast cancer patients in Turkey during the COVID-19 pandemic. Future
Oncology, 17(25), 3373-3381. https://doi.org/10.2217/fon-2020-1265
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta
Psychiatrica Scandinavica, 67(6), 361-370.

Copyright © 2023 NMJN. This article is an open-access article distributed under the terms and conditions of the
Creative
Commons
Attribution-Share
Alike
4.0
(CC
BY-SA)
International
License
(https://creativecommons.org/licenses/by-sa/4.0).

Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811