Acculturation and Quality of Life among Chinese American Breast Cancer Survivors: The Mediating Role of Self-stigma, Ambivalence over Emotion Expression, and Intrusive Thoughts

Abstract

Objectives:

Highly acculturated Chinese American breast cancer survivors have greater access to healthcare providers, are English language proficient, and have more knowledge about the health care system. However, less is known about the potential psychosocial factors that may account for the health benefits of acculturation. As such, the current study seeks to understand how mainstream acculturation is associated with higher quality of life by investigating self-stigma, ambivalence over emotion expression (AEE), and intrusive thoughts, as serial mediators among Chinese breast cancer survivors.

Methods:

112 Chinese American breast cancer survivors completed a self-reported questionnaire with these trait variables.

Results:

We found support for a serial multiple mediation hypothesis in which mainstream acculturation was indirectly associated with quality of life through self-stigma, AEE, and intrusive thoughts. Specifically, mainstream acculturation was associated with lower self-stigma, which in turn was associated with lower AEE and intrusive thoughts, and subsequently resulted in lower quality of life among Chinese American breast cancer survivors.

Conclusions:

The findings suggest that psychosocial factors are important mechanisms through which acculturation is associated with quality of life among Chinese American breast cancer survivors. As Chinese immigrants acculturate to mainstream American culture, they may benefit from the reduced public stigma toward breast cancer and incorporate new post-immigration knowledge about cancer that protects them from high levels of self-stigma. This in turn may lead Chinese American breast cancer survivors to experience lower AEE and intrusive thoughts, and subsequently experience higher quality of life.

Background

Asian Americans are the fastest growing racial group in the US with Chinese Americans representing the oldest and largest Asian sub-group[1]. Chinese Americans are diverse in their immigration history, spoken dialect, socioeconomic background, and geographic settlement[2]. Contributing to the heterogeneity, Chinese Americans have different experiences of acculturation, defined as the process of adaptation and adjustment immigrants experience in a new country[3], that can affect quality of life. For example, Chinese American breast cancer survivors who endorse more US mainstream cultural values report less discrimination by healthcare providers and have greater knowledge about the health care system[4]. These issues reflect an important public health concern among Chinese Americans given steady rise in breast cancer incidence[5].

While the positive link between acculturation to US culture and quality of life among Chinese breast cancer survivors has been well-documented [4], less is known about the potential psychosocial factors that may mediate this relationship. One possible explanation is that perceptions of disease, such as stigma or negative beliefs about cancer, become less negative during the acculturation process. In turn, the shift towards more positive beliefs about the meaning of cancer can increase the cancer survivors’ willingness to disclose their cancer-related thoughts, thereby increasing their quality of life. Understanding the psychosocial factors that mediate the link between acculturation and quality of life can provide another potentially promising target of intervention for Chinese American breast cancer survivors with various levels of acculturation. Thus, the current study seeks to understand how mainstream acculturation is associated with higher quality of life by investigating self-stigma, ambivalence over emotion expression (AEE), and intrusive thoughts, as serial mediators among Chinese breast cancer survivors.

Acculturation and self-stigma among Chinese American breast cancer survivors

The heterogeneity in adjustment to cancer may be influenced by differences in the perception and management of cancer as a result of cultural identification. That is, culture can shape cancer survivors’ beliefs about how others perceive themselves and how to behave around others based on these beliefs. With successful philanthropic efforts such as the Pink Ribbon campaign and cancer-related public health events (e.g., charity runs), the negative perceptions and public stigma toward breast cancer have decreased in the US since the mid-20^th century[6]. However, the emotional and psychological benefits of reduced public stigma toward breast cancer may be limited to highly acculturated Chinese American breast cancer survivors. For example, these individuals are likely to be English proficient and have social interactions with Americans who may be more supportive about cancer (i.e., due to reduced public stigma). In contrast, among the Chinese American breast cancer survivors who are less acculturated, they may have traditional cultural beliefs that are associated with stigmatized beliefs about cancer. Supporting this notion, qualitative studies demonstrate that less acculturated Chinese American breast cancer survivors continue to endorse self-stigma, defined as internalized negative beliefs about a social identity. For instance, Chinese American breast cancer survivors believe that cancer inevitably causes death, results from immoral behavior[7], and they will lose face and bring shame to the family if others find out about it[8]. Likely reinforcing these stigmatized beliefs among breast cancer survivors, a recent qualitative study showed that the same beliefs were held among Chinese women without a history of breast cancer[9]. The limited quantitative research in this area has shown that cancer-related stigma negatively predicted impact quality of life among a sample of Latina breast cancer survivors[10]. The question remains, however, if lower self-stigma about breast cancer may account for the psychological benefits of acculturation.

We draw from the Cognitive-Affective-Behavioral model of concealing stigma [11] and the Social-Cognitive Processing model of emotional adjustment to cancer[12] to understand how self-stigma and emotional inhibition negatively impact quality of life among Chinese breast cancer survivors. A person with a concealable stigma is faced with the dilemma of choosing whether, to whom, when and how to reveal their stigmatized identity[13]. According to the Cognitive-Affective-Behavioral model of stigma, stigma-salient situations can trigger cognitive and affective responses (e.g., shame) that increase the likelihood of concealment behaviors (e.g., social avoidance)[11]. These resulting fear of being discovered or the experience of shame may lead to discomfort with or an unwillingness to express their emotions. By engaging in concealment behaviors, pre-existing beliefs about the self and the stigmatized identity remain unchallenged. The effect of these behaviors on the quality of life of breast cancer survivors is further outlined in the Social-Cognitive Processing model, which underscores the detrimental effects of social constraints[14]. The model asserts that perceived limitations in the social environment to engage in stress-related conversations impede breast cancer survivor adjustment. That is, breast cancer survivors who have stigmatized beliefs or perceive an unsupportive environment are less likely to process difficult emotions that would otherwise be helpful in re-establishing self-efficacy and positive self-concept. The current study examines ambivalence over emotion expression (AEE) and intrusive thoughts as mediators that may account for the relationship between self-stigma and lower quality of life.

Breast cancer survivors may experience internal tension around expressing or suppressing emotions regarding one’s illness during stigma-salient situations. For example, a Chinese breast cancer survivor may want to express anxiety to elicit more support from her family but chooses to suppress her emotions because of the shame she feels for having cancer. This type of inner conflict is also known as AEE[15] and is characterized by a desire to express emotions but fearing the consequences of such expression[16]. AEE is elevated among breast cancer patients compared with healthy controls[16], suggesting that this emotional conflict may be influenced by the experience of breast cancer. AEE has been linked with lower quality of life among Chinese American breast cancer survivors[17], with this relationship mediated by lower social support among Chinese breast cancer survivors and avoidance coping among rheumatoid arthritis patients [18,19]. While AEE is generally considered a trait-like characteristic, it has also been studied as a mediator[20]. For example, AEE mediated the relationship between self-criticism and depression[21], and considered an mediator in the relationship between emotional styles and well-being[15]. Therefore, we examine AEE as a mediator in the present study.

In addition to AEE, breast cancer survivors may experience intrusive thoughts as a result of cognitive efforts to suppress thoughts or conceal aspects related to the stigmatized identity. Paradoxically, suppressing thoughts can increase the intrusive thoughts and set off a feedback loop that further intensifies negative effects of concealment[22]. For example, stigma-salient situations may trigger a cyclical pattern of unpleasant thoughts and suppression causing significant distress. Thus, AEE and intrusive thoughts may be two cognitive and affective factors that mediate the self-stigma and quality of life relationship.

Current Study

A paucity of research has examined the cognitive and affective factors that account for the positive link between acculturation and quality of life, and far fewer among Chinese American breast cancer survivors. Based on the Cognitive-Affective-Behavioral model of stigma[11] and the Social-Cognitive Processing model of cancer adjustment[12], the purpose of the present study was to investigate potential cognitive and affective factors that mediate the link between mainstream acculturation and quality of life. First, we propose that greater endorsement of mainstream cultural values would be related to better quality of life among Chinese American breast cancer survivors. Then, we hypothesized a serial multiple mediation model, such that this relationship would be mediated by self-stigma, which in turn would be mediated by intrusive thoughts and AEE. Specifically, acculturation would be associated with lower self-stigma, which in turn would be associated with less AEE and intrusive thoughts, which in turn would be associated with greater quality of life.

Methods

Participants and Procedure

The present study utilized the baseline data of a larger longitudinal study that examined the prospective relations between emotion regulation, coping, and health [23]. The entire study, including all communications between research staff and participants, was conducted in Chinese in collaboration with our community partner, Herald Cancer Association (HCA). HCA provides Chinese-translated resources on breast cancer, offers support groups, and host cancer awareness events for the community. Participants were recruited from branch offices of HCA, located in Los Angeles, New York City, and Dallas, through phone, email, text messaging, and face-to-face during cancer-related community events. Participants were told that the present study aimed to better understand their cancer experiences. Interested participants were sent a package that consisted of a consent form, self-reported questionnaire, and a stamped return envelope. The study was approved by the Institutional Review Board (IRB #: 11223–02) and all participants provided written informed consent.

Study questionnaires that were not previously translated to Chinese were translated to Chinese following established protocols for cross-cultural research [24]. The survey items were first translated into Chinese by a member of the bilingual research team, and then back translated by research team member into English. A third research team member then compared the original English version with the back-translated version until each item was equivalent in meaning.

In total, 112 Chinese breast cancer survivors participated in the present study (M_age = 58.89, SD = 9.48). Demographic and medical information are provided in Table 1. All participants in the present study were foreign-born immigrants.

Table 1.

Demographic and Medical Information

Variable
Age (years)
Mean (SD)	58.89(9.48)
Range	39–90
Time since diagnosis (months)
Mean (SD)	85.11(70.81)
Range	8–351
Education	Percentage
Below high school	13.4%
some high school	2.7%
high school graduate	22.3%
some college	25.9%
college degree	20.5%
post-graduate degree	14.3%
Missing	0.9%
Annual household income
less than $15,000	25.9%
$15,000–$45,000	39.3%
$45,000–$75,000	16.1%
More than $75,000	11.6%
Missing	7.1%
Marital Status
Never married	8.9%
Married	74.1%
Widowed	4.5%
Separated	2.7%
Divorced	8.9%
Missing	0.9%
Stage of breast cancer
0	11.6%
I	29.5%
II	41.1%
III	16.1%
Missing	1.8%
Treatments Undergone
Surgery
Yes	81.3%
No	15.2%
Missing	3.6%
Chemotherapy
Yes	61.6%
No	36.6%
Missing	1.8%
Radiation
Yes	56.3%
No	41.1%
Missing	2.7%
Other Medications
Yes	42%
Yes, but not currently	29.5%
Never	26.8%
Missing	1.8%

Measures

Mainstream acculturation.

Acculturation to mainstream American culture was assessed with the dominant society immersion subscale of the Stephenson Multigroup Acculturation Scale (SMAS)[25]. While the original dominant society immersion subscale of the SMAS contains 16 items, only 3 items (i.e., “I attend social functions with American people”, “I have many American acquaintances”, and “I speak English at home”) were administered to the participants to decrease participant burden. Participants rated these 3 items on a 4-point Likert scale (0 = “False”, 3 = “True”). Extant research has documented the validity of assessing acculturation with a few items, as well as the importance of assessing English language use as an important aspect of acculturation among Asian immigrants[26]. The SMAS has been validated to be used with Chinese populations[27]. Higher scores indicate greater acculturation to mainstream American culture. The internal reliability of the present sample was adequate (Cronbach’s α = 0.75).

Self-stigma.

Self-stigma was assessed with the Self-Stigma Scale-Short Form (SSS)[28]. The SSS is a 9-item self-reported questionnaire that was first developed in Chinese and validated with Hong Kong Chinese to assess internalized stigma related to minority status such as HIV. We replaced the minority descriptions in the items (e.g., HIV status) with “breast cancer survivor” in the present study. Participants rated the items (e.g., “My identity as a breast cancer survivor is a burden to me”) on a 4-point Likert scale (1 = “Strongly Disagree”, 4 = “Strongly Agree”). The reliability and construct validity of the SSS has been established in previous research with Chinese populations[28]. Higher scores indicate higher levels of self-stigma. The internal reliability of the present sample was adequate (Cronbach’s α = 0.95).

AEE.

AEE was assessed with the Ambivalence over Emotional Expressivity Questionnaire (AEQ)[15]. The original AEQ is a unidimensional 28-item self-reported questionnaire. However, four items were removed based on feedback from a community sample of Chinese breast cancer survivors (e.g., “I try to control my jealousy concerning my boyfriend/girlfriend even though I want to let them know I’m hurting”). Participants rated the items on a 5-point Likert scale (0 = “Never”, 4 = “Frequently”). Higher scores indicate higher levels of AEE. The internal reliability of the present sample was adequate (Cronbach’s α = 0.93).

Intrusive thoughts.

Cancer-related intrusive thoughts were assessed with the 7-item intrusion subscale of the Chinese version of the Impact of Event Scale (IES-C)[29]. Sample items include “Other things kept making me think about it” and “I thought about it when I didn’t mean to.” Participants rated the items on a 5-point Likert scale (0 = “Not at all distressing” to 4 = “Very distressing”). The IES has been previously validated with Chinese cancer survivors[29]. Higher scores indicate higher levels of intrusive thoughts. The internal reliability of the present sample was adequate (Cronbach’s α = 0.90).

Quality of life.

Quality of life was assessed with the Chinese version of the Functional Assessment of Cancer Therapy-Breast (FACT-B)[30]. The FACT-B is a 27-item self-report questionnaire with multiple subscales, including physical (e.g., “I have a lack of energy”), emotional (e.g., “I am losing hope in the fight against my illness”), functional (e.g., “I am able to work”), and social well-being (e.g., “I get emotional support from my family”). Participants rated each item on a 5-point Likert scale (0 = “Not at all”, 4 = “Extremely”). A quality of life composite variable was created by summing each subscale. Higher scores indicate higher quality of life. The internal reliability of the present sample was adequate (Cronbach’s α = 0.95).

Data Analysis Plan

To examine the serial multiple mediation, path analysis was conducted using Mplus 7.0 [31]. Mplus handles missing data using full-information maximum likelihood (FIML) estimation and bootstrapping was implemented to obtain bias-corrected 95% confidence intervals for assessing the significance of the specific indirect effects. The absence of zero in the confidence intervals suggest a significant indirect effect. The model tested included age, stage at diagnosis, and annual family income as covariates.

Results

Descriptive statistics and bivariate correlations are presented in Table 2. Mainstream acculturation was associated with lower self-stigma (r = −.32, p < .001), intrusive thoughts (r = −.21, p < .05), and higher quality of life (r = .30, p < .01). However, mainstream acculturation was not associated with AEE (r = −.04, p > .05).

Table 2.

Correlations and Descriptive Statistics of Study Variables

Variable	1	2	3	4	5	M (SD)	Range
1. Mainstream Acculturation	--					3.42 (2.37)	[0,9]
2. Self-Stigma	−.32***	--				16.30 (7.18)	[3,35]
3. AEE	−.04	.40***	--			46.34 (18.83)	[2,83]
4. Intrusive Thoughts	−.21*	.63***	.42***	--		10.13 (7.57)	[0,30]
5. Quality of Life	.30**	−.50***	−.39***	−.53***	--	77.74 (18.97)	[28,108]

Note.

^*p < .05

^**p < .01

^***p < .001

AEE = Ambivalence over emotional experience.

Path Model

The hypothesized model indicated inadequate model fit: χ²(10) = 18.18, p > .05. CFI = .94, RMSEA = .10, SRMR = .06. Perhaps reflecting the underlying similarities as cognitive mediators of the link between self-stigma and quality of life, modification indices suggested allowing the error variance of AEE and intrusive thoughts to covary. After making this adjustment, the model fit the data well according to standard conventions[32], χ²(9) = 11.83, p = .22. CFI = .98, RMSEA = .06, SRMR = .05. The standardized parameter estimates of this model are shown in Figure 1, and the corresponding coefficients for all paths for the full process model are presented in Table 3.

Figure 1.

Serial multiple mediation path model with standardized parameter estimates. Solid black lines indicate significant paths at p < .05. Dashed lines indicate non-significant paths. Estimate in the parenthesis reflects the total effect. Model fit indices: χ²(9) = 11.83, p = .22. CFI = .98, RMSEA = .06, SRMR = .05. **p < .01.

Table 3.

Standardized path estimates and bias-corrected 95% confidence intervals for all paths of the full serial multiple mediation model.

Path	Estimate	p-value	95% CIbc
Total Effect
Acculturation → QoL	.28	.01	[.08, .47]
Direct Effect
Acculturation → QoL	.13	.15	[−.05, .30]
Specific Indirect Effect
Acculturation → Stigma → QoL	.05	.29	[−.04, .15]
Acculturation → AEE → QoL	−.02	.54	[−.09, .02]
Acculturation → Intrusive Thoughts → QoL	−.004	.89	[−.06, .06]
Acculturation → Stigma → AEE → QoL	.03	.09	[.01, .09]
Acculturation → Stigma → Intrusive Thoughts → QoL	.08	.01	[.03, .16]
Total Indirect Effect	.15	.01	[.03, .27]

Note. QoL = quality of life. AEE = Ambivalence over emotion expression.

The total effect of mainstream acculturation on quality of life was significant (β = .28, p = .01). The specific indirect effect through self-stigma only (i.e., acculturation → self-stigma → quality of life) was not significant (estimate = .05, 95% CI_bc = [−.04, .15]). Similarly, the indirect effects through intrusive thoughts (acculturation→intrusive thoughts→quality of life) and AEE (acculturation→AEE→ quality of life) only were not significant (estimates = −.004 and −.02, 95% CI_bc = [−.06, .06] and [−.09, .02], respectively). However, as predicted, the relationship between mainstream acculturation and quality of life was fully mediated by the serial mediators of self-stigma, AEE, and intrusive thoughts (mainstream acculturation→self-stigma→AEE→quality of life, and mainstream acculturation→self-stigma→ intrusive thoughts→quality of life). Mainstream acculturation was associated with lower self-stigma (β = −.37, p < .001), which in turn was associated with lower AEE (β = .43, p < .001) and intrusive thoughts (β = .65, p < .001), and ultimately associated with greater quality of life (βs = −.21 and −.35, ps < .05, respectively). The specific indirect effect of the self-stigma→AEE and self-stigma→intrusive thoughts serial mediators were significant (point estimates = .03 and .08, 95% CI_bc = [.01, .09] and [.03, .16], respectively). With the inclusion of the serial mediators, the direct effect of mainstream acculturation on quality of life was non-significant (β = .13, p = .15).

Although the hypothesized serial mediation is theoretically supported, the cross-sectional data make the alternate direction of the model plausible. We tested an alternate model with AEE and intrusive thoughts preceding self-stigma in the serial mediation. Specifically, we tested the following serial mediation paths: 1) mainstream acculturation→AEE→self-stigma→quality of life, and 2) mainstream acculturation→intrusive thoughts→self-stigma→quality of life. Supporting our hypothesized serial mediation model, we found that the specific indirect effects for both alternate serial mediation paths were not significant (point estimates = .002 and .02, 95% CI_bc = [−.001, .02] and [−.009, .06], respectively).

Discussion

Extant research has identified the relationship between mainstream acculturation and higher quality of life among immigrant cancer survivors through its links with socio-ecological and healthcare system factors[33]. However, less is known about psychosocial factors that elucidate how mainstream acculturation is associated with quality of life. Thus, the present study investigated the potential for self-stigma, AEE, and intrusive thoughts to serve as serial mediators of mainstream acculturation and quality of life. We found support for the serial multiple mediation hypothesis that mainstream acculturation was indirectly associated with quality of life through self-stigma, AEE, and intrusive thoughts. Specifically, mainstream acculturation was associated with lower self-stigma, which in turn was associated with lower AEE and intrusive thoughts, and subsequently resulted in lower quality of life among Chinese American breast cancer survivors.

Self-stigma, AEE, and intrusive thoughts served as serial mediators of the relationship between mainstream acculturation and quality of life. Highly acculturated Chinese breast cancer survivors with less internalized stigma may have less intense fears of judgment and a greater willingness to share their cancer-related thoughts and feelings with others[7,10]. With lower social constraint from lower levels of self-stigma, Chinese American breast cancer survivors may have less AEE as they experience more comfort with disclosing their distress. This interpretation is consistent with a recent study among Chinese breast cancer survivors that found the relationship between social constraint and depressive symptoms to be mediated by AEE[34]. Similarly, the low levels of self-stigma may prompt individuals to disclose their cancer experiences with others, thereby decreasing intrusive thoughts[35].

We found that the indirect effects of AEE, intrusive thoughts, or self-stigma alone on the relationship between mainstream acculturation and quality of life were nonsignificant. From a theoretical perspective, the data provide preliminary evidence that it is appropriate to conceptualize these psychosocial predictors as serial, rather than simple mediators of the relationship between mainstream acculturation and quality of life. Furthermore, we further tested the alternate serial-mediation direction because of the cross-sectional data and found that they were non-significant. Thus, the data suggests a potential temporal order in how mainstream acculturation would be associated with higher quality of life over time through reducing self-stigma, and in turn, AEE and intrusive thoughts. However, caution is needed in interpreting our results as future research using a longitudinal design is needed to support the causal relationships implied by the serial multiple mediation. Future research may also expand on acculturative processes by testing the role of bicultural identity on self-stigma.

Clinical Implication

Our findings showed that negative cultural beliefs about cancer have important associations with quality of life. To practice culturally-competent care with immigrants, healthcare providers (e.g., oncologists, patient navigators, social workers) who work with Chinese American breast cancer survivors should be familiar with the common Chinese cultural beliefs that may be associated with self-stigma (e.g., cancer is a result of bad karma), and encourage them to disclose their cancer-related distress in a culturally-sensitive way that considers the acculturation level of the patient. For example, if the Chinese American breast cancer survivor is less acculturated, they may have greater internalized stigma that makes it difficult for them to ask question about their cancer diagnosis or express negative emotions. Greater attention and care may be needed with this population to help facilitate support seeking behaviors and access to health resources. Interventions that provide culturally-sensitive opportunities to process cancer-related distress and education may be helpful for reducing AEE and intrusive thoughts. For example, Tai Chi is a moderate form of exercise that have been found to have positive effects on self-esteem, mood, and quality of life among breast cancer survivors[36]. Similarly, writing-based interventions such as expressive writing have been found to improve quality of life among Chinese American breast cancer survivors[37], and those with higher levels of AEE may particularly benefit from this intervention[38].

Study Limitations

The current study also has several limitations that should be considered. First, our assessment of self-stigma precludes us from understanding the specific cultural beliefs that may be influenced by acculturation to mainstream culture. Future research that utilizes mixed-method design may address this gap by supplementing the self-reported questionnaire with an ethnographic interview to provide more robust context and meaning to acculturation, self-stigma and quality of life among Chinese American breast cancer survivors. Second, our study findings may not generalize to other Asian American groups such as Filipino Americans who have a different immigration history[39]. Relatedly, as our study was limited to foreign-born immigrants who are native speakers of Chinese, further research is needed to test whether these findings generalize with 2^nd generation Chinese Americans. These differences in immigration history can influence acculturation levels and distinctly shape adjustment to breast cancer. Lastly, our understanding of acculturation processes is limited by only considering individual-level influences (e.g., self-stigma, quality of life) in this study (Lopez-Class, Castro, & Ramirez, 2011). Other studies may include contextual-level dimensions, such as community (e.g., ethnic enclaves) and institutions (e.g., health care). Relatedly, future studies should investigate multi-dimensional approaches for assessing acculturation (e.g., identification with the ethnic minority culture).

Conclusions

We found that as Chinese immigrants acculturate to mainstream American culture, they may incorporate new post-immigration knowledge and receive social support that protects them from self-stigma. This in turn may lead Chinese American breast cancer survivors to believe that they can disclose cancer-related thoughts and feelings with others, experience lower AEE and intrusive thoughts, and subsequently experience higher quality of life. Overall, our study contributes to the literature by demonstrating a unique serial multiple mediation pathway through self-stigma, which involves negative beliefs that are heavily influenced by traditional Chinese values.