The Association of Social Support and Leisure Time Physical Activity With Mental Health Among Individuals With Cancer

Abstract

Purpose:

This study examined the relationship among social support, leisure time physical activity (LTPA), and mental health among people with cancer.

Design:

Cross-sectional study.

Setting and participants:

Using the 2017 Health Information National Trends Survey, we extracted data of 504 respondents who had been diagnosed with any of the 22 types of cancer listed in the survey questionnaire.

Measures:

As independent variables, we assessed 3 different types of support: emotional, informational, and tangible support. As mediating and outcome variables, we measured LTPA and mental health, respectively.

Analysis:

Using AMOS version 22, a path analysis was conducted to measure model fit. A mediation test was then conducted using bootstrapping procedures.

Results:

The hypothesized model provided an acceptable fit to the data. Specifically, emotional support (b = .15, p = .005), informational support (b = .13, p = .008), tangible support (b = .12, p = .010), and LTPA (b = .14, p = .001) were significantly associated with mental health. We revealed a significant mediating effect of LPTA on the relationship between emotional support and mental health (Estimate = .037, 95% CI = .001–.098, p < .05).

Conclusion:

Social support and LTPA played a significant role in promoting mental health among people with cancer. In particular, the results confirmed that individuals with cancer who reported receiving emotional support tended to engage in LTPA and thus reported better mental health.

Keywords

leisure time physical activity social support mental health cancer

Purpose

Compared to the general population, individuals with cancer are more likely to report social and psychological problems and concerns.^1,2 More specifically, individuals with cancer often experience anxiety, depression, social and emotional loneliness, and a sense of hopelessness.^3

-7 For example, based on the 2010 Behavioral Risk Factor Surveillance System (BRFSS) data, Zhao and colleagues⁸ found that cancer survivors (13.7%) were more likely to report depression than those without cancer (8.9%). In addition, emotional loneliness was found to be more prevalent among cancer patients when compared with those without cancer.⁴ Given the prevalence of mental disorders in cancer patients, there is a strong need for developing psycho-oncological interventions for individuals with cancer.

A growing body of literature suggests that social support serves as an important role in reducing negative psychological problems and symptoms among individuals with cancer.^9,10 According to the National Cancer Institute, social support refers to “a network of family, friends, neighbors, and community members that is available in times of need to give psychological, physical, and financial help.”¹¹ In general, researchers have categorized social support into 3 types: informational, tangible, and emotional,¹² and these 3 types are the most commonly studied in research on social support for cancer patients.¹³ In the present study, informational support involves the provision of useful or needed information and advice which could help a person cope with current difficulties.¹² Tangible support refers to the provision of material goods or actions that could help the individual in challenging situations, such as financial assistance or help with daily chores.¹² Emotional support includes the expression of empathy, caring, reassurance, and trust, and provides opportunities for emotional expression and venting.¹²

Mardanian-Dehkordi and Kahangi¹⁴ found that receiving lower levels of informational support from family, friends, and relatives (e.g., giving information and advice) were associated with higher fatigue scores among cancer patients. Zheng and colleagues¹⁵ indicated that the need for tangible support, such as receiving financial assistance, was one of the most worrisome issues for cancer patients. Some studies particularly emphasized the role of emotional support in improving the mental health of individuals with cancer.^16

-19 For example, Schroevers et al.²⁰ found that cancer patients with higher levels of emotional support tended to report lower levels of depressive symptoms. In light of these findings, receiving social support is an important contributor to mental health among individuals with cancer.

Empirical studies have also provided evidence that participation in leisure time physical activity (LTPA) is positively associated with mental health among individuals with cancer.^21

-25 For example, a population-based study of rural breast cancer survivors revealed that those who met the physical activity guideline (≥150 min of moderate intensity or ≥75 min of vigorous exercise per week or an equivalent combination) had significantly lower scores on depression than those who did not meet the guidelines.²⁶

Moreover, prior studies have suggested that social support plays an important role in facilitating LTPA involvement.^27
-29 For example, Coleman, Berg, and Thompson³⁰ found that greater social support from friends, such as words of encouragement and a strong feeling of love, can increase cancer survivors’ likelihood of taking advantage of LTPA opportunities. A qualitative study by Cummins et al.³¹ conducted interviews with cancer survivors to identify facilitators of engagement in LTPA. In that study, cancer survivors stated that significant others, such as family and friends, often helped them return to physically active lifestyle through verbal encouragement and peer support.

By connecting existing findings, we suggest that social support and LTPA play a significant role in determining the quality of mental health of individuals with cancer. Change et al.³² examined the relationship among social support, LTPA, and psychological well-being in older adults; however, less is known about this relationship among individuals with cancer. More saliently, a few studies have focused on the mediating role of LTPA in the relationship between social support and mental health among individuals with cancer. Therefore, we investigated whether emotional, informational, and tangible forms of support have direct positive effects on the mental health of individuals with cancer and on their participation in LTPA, whether LTPA has a direct positive effect on their mental health, and whether LTPA mediates relationships between social support and mental health. Specifically, the following 4 hypotheses were tested as part of this model:

H1: Social support has a direct positive effect on mental health among individuals with cancer.

H2: Social support has a direct positive effect on leisure time physical activity among individuals with cancer.

H3: Leisure time physical activity has a direct positive effect on mental health among individuals with cancer.

H4: Leisure time physical activity has a mediating effect on the relationship between social support and mental health among individuals with cancer.

Methods

Data Source

This study used the 2017 Health Information National Trends Survey (HINTS), a nationally representative survey of non-institutionalized adults in the United States. The HINTS includes a wide range of health information, including cancer prevalence, health status, and health-related behaviors, as well as public use of health-related information. The 2017 HINTS conducted random-digit dialing telephone surveys to provide a nationally represented sample of U.S. households. The 2017 HINTS has a sample of 3,285. For the purpose of this study, we used the survey question, “Have you ever been diagnosed as having cancer?” Finally, we extracted 504 respondents who had been diagnosed with any of the 22 types of cancers listed in the survey questionnaire.

Measures

Social support

As independent variables, this study included the 3 primary types of support: emotional, informational, and tangible support. Emotional support was measured through the following question: “Is there anyone you can count on to provide you with emotional support when you need it—such as talking over problems or helping you make difficult decisions?” with dichotomous response options of (1) yes and (0) no. Informational support was measured through the following question: “Do you have friends or family members that you talk to about your health?,” with dichotomous response options of (1) yes and (0) no. Tangible support was measured through the following question: “If you needed help with your daily chores, is there someone who can help you?” with dichotomous response options of (1) yes and (0) no.

Leisure time physical activity (LTPA)

LTPA was assessed by asking respondents to indicate the number of days and the duration of the moderate-intensity physical activities that they undertook in a typical week, such as sports, recreation activities, or exercise. Moderate-intensity physical activity was considered as 4.0 MET (i.e., the metabolic equivalent of task), and thus continuous scores for LTPA were calculated as follows:

[Total MET-minutes/week = MET level (4) x minutes of activity per day x days per week]

Mental health

Mental health was measured by 4 questions regarding little interest or pleasure in doing things, hopelessness, nervousness, and worrying. Specifically, respondents were asked to indicate how often each of these problems had bothered them over the past 2 weeks on a 4-point Likert-type scale (1 = Nearly every day, 2 = More than half the days, 3 = Several days, and 4 = Not at all). The values of these 4 mental health indicators were then added together and averaged to provide a single continuous mental health variable. Higher scores indicated that respondents were less frequently bothered by the problems indicated and thus had better mental health. The scale yielded a Cronbach’s α of .87.

Data Analysis

Using SPSS version 24.0, descriptive statistics were used to identify participant characteristics with regard to demographics (Table 1) and study constructs (Table 2). Cronbach’s alpha coefficients were used to measure internal consistency for the measure of mental health. Pearson correlation coefficients (Table 3) were used as the bi-variate analysis procedure for examining the relationship between continuous independent and meditating variables and the dependent variable. Using AMOS, path analysis was conducted to measure model fit and to examine how different types of social support and LTPA levels are associated with mental health among individuals with cancer. In this analysis, age, education, and household income were controlled because of their potential effects on mental health. In addition to model testing, the mediating role of LTPA in the relationship between social support and mental health among individuals with cancer was also tested using bootstrapping procedures. Finally, standardized beta coefficients from regression equations between the 3 types of support, LTPA, and mental health were calculated and are presented in Figure 1 and Table 4.

Table 1.

Demographic Characteristics of Individuals With Cancer.

Gender	N	Valid %
Female	288	61.3
Male	182	38.7
Annual household income	N	Valid %
$0-$9,999	33	6.5
$10,000 or 14,999	30	6.0
$15,000-$19,999	31	6.2
$20,000-$34,999	81	16.1
$35,000-$49,999	55	10.9
$50,000-74,999	95	18.8
$75,000-$99,999	59	11.7
$100,000-$199,999	85	16.9
$200,000 or more	33	6.5
Race/ethnicity	N	Valid %
White	340	67.5
Black	51	10.1
Hispanic	36	7.1
Asian	5	1.0
Other	17	3.4

Table 2.

Means and Standard Deviations for Study Constructs.

Variable	Individuals with cancer (N = 504)
Variable	M	SD
Emotional Support
Is there anyone you can count on to provide you with emotional support when you need it—such as talking over problems or helping you make difficult decisions?	.88	.33
Informational Support
Do you have friends or family members that you talk to about your health?	.92	.28
Tangible Support
If you needed help with your daily chores, is there someone who can help you?	.78	.41
Mental Health	3.47	.70
Little interest or pleasure in doing things	3.37	.95
Feeling down, depressed, or hopeless	3.53	.79
Feeling nervous, anxious, or on edge	3.45	.83
Not being able to stop or control worrying	3.51	.79
Leisure Time Physical Activity(MET-minutes per week)	744.68	1429.17

*p < 0.05, **p < 0.01, ***p < 0.001

Table 3.

Pearson Correlations of Independent Variables and Mental Health.

Variable	1.	2.	3.	4.	5.
1. Emotional support	1
2. Informational support	.57**	1
3. Tangible support	.42**	.34**	1
4. LTPA	.10*	.02	.06	1
5. Mental health	.33**	.29**	.28**	.22**	1

* p < .05. **p < .001.

Figure 1.

Final path model of mental health among individuals with cancer.

Table 4.

Direct Effects of Social Support on LTPA and Mental Health Among People With Cancer.

Dependent Variable and Path			β (SE)	t-value	R ²	Hypothesis
Mental health					.26
Emotional support	→	Mental health	0.15(0.12)	2.82**	-	H1: Supported
Informational support	→	Mental health	0.13(0.13)	2.63**	-	H1: Supported
Tangible support	→	Mental health	0.12(0.08)	2.57*	-	H1: Supported
LTPA	→	Mental health	0.14(0.02)	3.36***	-	H3: Supported
LTPA					.08
Emotional support	→	LTPA	0.12(0.25)	2.02*	-	H2: Supported
Informational support	→	LTPA	0.08(0.28)	-1.40	-	H2: Not supported
Tangible support	→	LTPA	0.04(0.17)	.82	-	H2: Not supported

* p < .05; **p < .01 and ***p < .001

Results

Descriptive Analysis

Descriptive statistics were used to identify cancer patients’ characteristics with regard to age, gender, race/ethnicity, education, income, perceived emotional social support, LTPA, and mental health (Table 1). The mean age of the participants was 67 years (SD = 12), and the sample comprised 288 females (61.3%), and 182 males (38.7%). Most of the participants were non-Hispanic White (67.5%). The most common educational level was “some college” (29.2%), followed by “high school graduate” (23.2%), and “a bachelor’s degree” (21.2%). The largest household income group was “$50,000 to $74,999” (18.8%), followed by “$100,000 to $199,999” (16.9%), and “$20,000 to $34,999” (16.1%).

Correlation Analysis

The results (Table 3) indicated that emotional support (r = .32, p = .001), informational support (r = .29, p = .001), tangible support (r = .28, p = .001), and LTPA (r = .22, p = .001) were positively associated with mental health. While emotional support was associated with LTPA (r = .10, p = .038), informational support (r = .02, p > .05) and tangible support (r = .06, p > .05) were not related to LTPA. The Pearson’s bivariate correlations did not approach the cut-off level of .80³³ and suggested that no multi-collinearity existed. In addition to the correlation test, the variance inflation factor (VIF) was examined in order to assess the degree of collinearity. In general, a VIF value less than 10 is considered acceptable.³⁴ In this study, the values of the VIF ranged between 1.01 and 1.65, confirming that no multi-collinearity existed in the data.

Path Analysis

The hypothesized model provided an acceptable fit to the data (χ²(df = 2) = 5.72, p = 0.057; RMSEA = 0.065; SRMR = 0.016; CFI =0.994). As shown in Table 4, the results indicated that emotional support (b = .15, p = .005), informational support (b = .13, p = .008), tangible support (b = .12, p = .010), and LTPA (b = .14, p = .001) were significantly associated with mental health among people with cancer. Therefore, Hypotheses #1 and #3 were supported. Emotional support was also associated with LTPA (b = .12, p = .033), whereas no significant effects were found between informational support and LTPA and between tangible support and LTPA. Therefore, Hypothesis #2 was partially supported. Across all of the study constructs, emotional social support had the strongest relationship to mental health (b = .15, p = .005), followed by LTPA (b = .14, p = .001). Overall, the model accounted for 26% of the variance in mental health (Table 4).

Mediation Test

Only one hypothesized path by which emotional support had a direct effect on mental health through its effect on LTPA was found to meet Baron and Kenny’s criteria.³⁵ We used a bootstrapping method³⁶ to examine whether LTPA had a significant indirect effect on the relationship between emotional support and mental health. The results indicated a significant indirect effect of LTPA on the relationship between emotional support and mental health (Estimate = .037, 95% CI = .001–.098, p < .05). Thus, Hypothesis #4 was partially supported.

Discussion

Results from this study indicated that all 3 types of support and LTPA were significantly associated with mental health. In particular, emotional support was found to be most strongly associated with mental health, followed by LTPA, informational support, and tangible support. These results corroborate several previous studies that suggest emotional support is particularly important for mental health among people with cancer.^17,19,20 In addition, we suggest that implementing peer support groups may be beneficial for individuals with cancer to receive and/or perceive emotional support. Ussher, Kirsten, Butow, and Sandoval³⁷ suggested that cancer peer support groups where individuals share the same problem can create unique bonding experiences and build supportive relationships with others, such as through a sense of community, unconditional acceptance, and information sharing. Such supportive and cohesive networks can help people with cancer express and receive validation for their emotions, which can improve their mental health.

Our study also found that people with cancer who had friends or family members with whom they could talk about health issues tended to report better mental health. This finding agrees Mardanian-Dehkordi et al.’s finding¹⁴ that cancer patients who had higher levels of informational support from family, friends, and relatives tended to score lower on cancer-related physical and mental fatigue. In addition, the results of our study indicated that individuals with cancer who had someone who could help with their daily chores were more likely to report better mental health. This finding is aligned with Merluzzi and colleagues’ finding³⁸ that such assistance could buffer the impact of physical debilitation on psychological stress among cancer patients. However, given limited evidence on the relationship of instrumental/tangible support to the health of cancer patients, further research in this area may be needed.

The results of the mediation test showed that individuals with cancer who had higher levels of emotional support were more likely to report higher levels of LTPA, which, in turn, led to better mental health. This finding is aligned with previous studies that examined Chang et al.’s³² finding that higher levels of social support led to greater LTPA participation, which, in turn, resulted in better psychological well-being among older adults. In addition, our study supports Cohen and Will’s³⁹ notion that higher social network support or lower social strain could benefit on health by encouraging health-promoting behaviors.

Based on our results, we suggest that designing and implementing interventions to increase emotional support and promote LTPA simultaneously can be an effective strategy by which to improve mental health among people with cancer. Prior studies have suggested that community-based interventions that help develop social support networks are cost-effective strategies for increasing LTPA and improving health.^40
-42 The primary benefits of such interventions may include increased encouragement and motivation to persevere, enhanced self-efficacy for and enjoyment of LTPA, and increased sense of social cohesion.^43

-46 That is, community-based programs and events where people with cancer can receive such social benefits have the potential to promote LTPA participation and improving mental health.

This study has some limitations. First, given the cross-sectional nature of the current data, no causal inferences can be drawn from our findings. Inversely, the results suggest that participation in LTPA may increase perceived emotional support. Future investigation is needed to examine casual relationships. Moreover, given the nature of the secondary data used, there is no information about the length of treatment since diagnosis, type of treatment, and severity of the cancer, which may affect LTPA participation and mental health. Thus, it is suggested that future research includes these as control variables. Second, the HINTS data provided only self-reported information on LTPA. Therefore, we acknowledge that biases (e.g., recall bias) could be present. Third, most of the individuals with cancer who participated in the study were non-Hispanic Whites (67.5%) and female (61.3%). Given this, the results of this study may not be generalizable across ethnic groups and genders. Future research could involve diverse samples to examine ethnicity and gender differences in the cancer population with regard to social support, LTPA, and mental health.

In conclusion, the current study revealed that the 3 primary types of support and LTPA played significant roles in the mental health of people with cancer. Moreover, the findings confirmed that emotional support had significant direct effects on mental health and was a significant contributor to LTPA participation, which also positively affected mental health. The findings from this study can inform policy-makers and health professionals on how to develop effective interventions to promote good health behaviors and improve mental health among individuals with cancer.

So What?

What is already known on this topic?

Social support and LTPA participation are shown to be positively associated with mental health among individuals with cancer. A significant positive relationship has also been found between social support and LTPA.

What does this article add?

We confirmed that emotional support had a direct effect on mental health through its effect on LTPA. That is, individuals with cancer who had higher levels of emotional support were more likely to report higher levels of LTPA, which, in turn, resulted in better mental health.

What are the implications for health promotion practice or research?

We suggest that promoting LTPA participation among people with cancer through positive social-emotional support can be an effective strategy by which to improve their mental health. Community-based programs and events where people with cancer can receive a variety of social benefits have the potential to promote LTPA participation and improve mental health.

Footnotes

Author's note

Areum Han is also affiliated with the Korea University Center for Curriculum and Institute of Studies, Korea University, Seoul, South Korea.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jaehyun Kim

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