Online Exclusive Article

A Path Analysis: A Model of Depression in Korean Women With Breast Cancer-Mediating Effects of Self-Esteem and Hope

Young Sook Tae

Margaret Heitkemper

Mi Yea Kim

hope, breast neoplasms, depression
ONF 2011, 39(1), E49-E57. DOI: 10.1188/12.ONF.E49-E57

Purpose/Objectives: To test a hypothetical model of depression in Korean women with breast cancer and to test the mediating effects of self-esteem and hope.

Design: Cross-sectional design.

Setting: Participants were recruited from three general hospitals and one cancer hospital in Busan, South Korea.

Sample: 214 Korean women diagnosed with breast cancer (stages I-III).

Methods: All participants completed questionnaires (e.g., Zung Self-Rating Depression scale, Herth Hope Scale, Rosenberg Self-Esteem Scale, Health Self-Rating Scale in Health and Activity survey, Kang's Family Support Scale). Based on the literature, Mplus, version 3.0, was used to determine the best depression model with path analysis.

Main Research Variables: Depression, self-esteem, hope, perceived health status, religious beliefs, family support, economic status, and fatigue.

Findings: Self-esteem was directly affected by perceived health status, religious beliefs, family support, economic status, and fatigue. Hope was directly affected by family support, self-esteem, and how patients perceived their health status. Depression was directly affected by self-esteem and hope. The path analysis model explained 31% of the variance in depression in Korean women with breast cancer.

Conclusions: A model of depression in Korean women with breast cancer was developed, and self-esteem and hope were mediating factors of depression.

Implications for Nursing: Self-esteem and hope must be considered when developing services to reduce depression in Korean women with breast cancer.

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    Anderson, M. S., & Johnson, J. (1994). Restoration of body image and self-esteem for women after cancer treatment: A rehabilitative strategy. Cancer Practice, 2, 345-349.
    Aspinwall, L. G., & Taylor, S. E. (1992). Modeling cognitive adaptation: A longitudinal investigation of the impact of individual differences and coping on college adjustment and performance. Journal of Personality and Social Psychology, 63, 989-1003.
    Bardwell, W. A., Natarajan, L., Dimsdale, J. E., Rock, C. L., Mortimer, J.E, Hollenbach, K., & Pierce, J. P. (2006). Objective cancer-related variables are not associated with depressive symptoms in women treated for early-stage breast cancer. Journal of Clinical Oncology, 24, 2420-2427. doi:10.1200/JCO.2005.02.0081
    Berterö, C. M. (2002). Affected self-respect and self-value: The impact of breast cancer treatment on self-esteem and quality of life. Psycho-Oncology, 11, 356-364. doi:10.1002/pon.577
    Boomsma, A., Duijn, M. V., & Snijders, T. (2001). Essays on item response theory (Lecture notes in statistics). New York, NY: Springer.
    Brothers, B. M., & Andersen, B. L. (2009). Hopelessness as a predictor of depressive symptoms for breast cancer patients coping with recurrence. Psycho-Oncology, 18, 267-275. doi:10.1002/pon.1394
    Brown, G. W., Andrew, B., Harris, T., Adler, Z., & Bridge, L. (1986). Social support, self-esteem and depression. Psychological Medicine, 16, 813-831.
    Burgess, C., Cornelius, V., Love, S., Graham, J., Richard, M., & Ramirez, A. (2005). Depression and anxiety in women with early breast cancer: Five year observational cohort study. BMJ, 330, 702-705. doi:10.1136/bmj.38343.670868.D3
    Chen, M. L. (2003). Pain and hope in patients with cancer: A role for cognition. Cancer Nursing, 26(1), 61-67.
    Chi, G. C. (2007). The role of hope in patients with cancer. Oncology Nursing Forum, 34, 415-424. doi:10.1188/07.ONF.415-424
    Cho, M. J., & Lee, J. Y. (2003). Ecology of depression. Journal of the Korean Medical Association, 46, 800-807.
    Chon, B. J. (1974). Self-esteem: A test of its measurability. Yonsei Introduction, 11, 107-124.
    Chun, J. Y., & Kim, H. J. (1996). A study on body image, spouse support and psychosocial adjustment of patient in mastectomy. Journal of Korean Academy of Adult Nursing, 8, 394-408.
    Curbow, B., Somerfield, M., Legro, M., & Sonnega, J. (1990). Self concept and cancer in adults: Theoretical and methodological issues. Social Science and Medicine, 31, 115-128. doi:10.1016/0277.9538(90)90053-u
    Dodd, M. J., Miaskowski, C., & Lee, K. A. (2004). Occurrence of symptom clusters. Journal of the National Cancer Institute. Monographs, 32, 76-78.
    Dufault, K., & Martocchio, B. C. (1985). Symposium on compassionate care and the dying experience. Hope: Its spheres and dimensions. Nursing Clinics of North America, 20, 379-391.
    Ebright, P. R., & Lyon, B. (2002). Understanding hope and factors that enhance hope in women with breast cancer. Oncology Nursing Forum, 29, 561-568. doi:10.1188/02.ONF.561-568
    Farran, C. J., Herth, K. A., & Popovich, J. (1995). Hope and hopelessness: Critical clinical constructs. Thousand Oaks, CA: Sage.
    Fitzgerald Miller, J. (2007). Hope: A construct central to nursing. Nursing Forum, 42(1), 12-19. doi:10.1111/j.1744-6198.2007.00061.x
    Folkman, S., & Lazarus, R. S. (1988). The relationship between coping and emotion: Implication for theory and research. Social Science and Medicine, 26, 309-317. doi:10.1016/0277-9538(88)90395-4
    Franks, H. M., & Roesch, S. C. (2006). Appraisals and coping in people living with cancer: A meta-analysis. Psycho-Oncology, 15, 1027-1037.
    Gibson, L. M., & Parker, V. (2003). Inner resources as predictors of psychological well-being in middle-income African American breast cancer survivors. Cancer Control, 10(5, Suppl.), 52-59.
    Ha, E. H., Seo, J. E., Jeong, J., Yang, J., Nam, S. J., & Lee, J. E. (2008). Biopsychosocial predictors of depressive disorder in breast cancer patients. Korean Journal of Clinical Psychology, 27, 961-976.
    Hamilton, J. B., Moore, C. E., Powe, B. D., Agarwal, M., & Martin, P. (2010). Perceptions of support among older African American cancer survivors. Oncology Nursing Forum, 37, 484-493. doi:10.1188/10.ONF.484-493
    Han, Y. I., Han, J. I., & Sohn, S. K. (2005). Relationship between pain and depression in patients with breast cancer. Korean Journal of Hospice Care, 5(2), 22-32.
    Herth, K. (1991). Development and refinement of an instrument to measure hope. Scholarly Inquiry for Nursing Practice, 5(1), 39-51.
    Hirai, K., Suzuki, Y., Tsuneto, S., Ikenaga, M., Hosaka, T., & Kashiwagi, T. (2002). A structural model of the relationships among self-efficacy, psychological adjustment, and physical condition in Japanese advanced cancer patients. Psycho-Oncology, 11, 221-229. doi:10.1002/pon.561
    Johnson, M. (1997). On the dynamics of self-esteem: Empirical validation of basic self-esteem and earning self-esteem (Doctoral dissertation). Stockholm University: Stockholm, Sweden. Retrieved from
    Kang, H. S. (1985). Experimental study of the effects of reinforcement education for rehabilitation on hemiplegia patients' self-care activities (Doctoral dissertation). Yonsei University: Seoul, South Korea. Retrieved from
    Kim, M. R. (2007). The relationship between housewives' stress and depression tendency: The mediating and moderating effects of self esteem and social support. Korean Journal of Health Psychology, 12, 761-777.
    Kim, S. Y. (1991). Relationship between older person's conceptualizations of time and health (Master's thesis). Ewha Women University: Seoul, South Korea. Retrieved from
    Korean Breast Cancer Society. (2008). 2006-2008 breast cancer facts and figures. Seoul, South Korea: Author.
    Korean Institute for Health and Social Affairs. (2010). Health and welfare information: National health and welfare trends. Retrieved from
    Kring, A. M., Davison, G. C., Neale, J. M., & Johnson, S. L. (2006). Abnormal psychology (pp. 236-276). Hoboken, NJ: John Wiley and Sons.
    Kwon, I. K. (1984). An exploratory study on awareness of disease, health locus of control, depression, and pain perception of cancer patients (Doctoral dissertation). Seoul National University: Seoul, South Korea. Retrieved from
    Kwon, O. J. (2006). Relationship between hope and depression in patients with breast cancer (Master's thesis). Kosin University: Busan, South Korea. Retrieved from
    Lazarus, R. S. (1991). Emotion and adaptation. New York, NY: Oxford University Press.
    Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer.
    Lee, E. H. (2001). Fatigue and hope: Relationships to psychosocial adjustment in Korean women with breast cancer. Applied Nursing Research, 14(2), 87-93. doi:10.1053/apnr.2001.22374
    Lee, M. S. (2005). Depression 119: Cold of the mind. Seoul, South Korea: Garam.
    Lee, M. S., Lee, W. H., Kim, K. S., Tae, Y. S., Suh, S. L., So, H. S., … Choi, E. O. (2007). Psychosocial nursing care and research for cancer patients. Seoul, South Korea: Soo Moon Sa Com.
    Lee, S. J., Kim, J., & Park, Y. M. (2008). Influence of depression on cancer metastasis. Journal of Korean Oncology Nursing, 8, 105-110.
    Lee, U. S. (2003). A study of Korean women's religiosity within the evolving process of Korean religious culture. Journal of Korean History of Thoughts, 21, 549-583.
    Lepore, S. J., Glaser, D. B., & Roberts, K. J. (2008). On the positive relation between received social support and negative affect: A test of the triage and self-esteem threat models in women with breast cancer. Psycho-Oncology, 17, 1210-1215. doi:10.1002lpon.1347
    Nam, J. J., & Choi, E. J. (2000). Korean women's health and policy based on nationwide survey on health and nutrition. The Second Symposium of the Korean Academic Society of Women's Health. Seoul, Korea: Ewha Women's University Press.
    National Cancer Information Center. (2010). Ministry of Health and Welfare and National Cancer Center. Retrieved from
    Northrup, C. (2001). The wisdom of menopause: Creating physical and emotional health and healing during the change. New York, NY: Bantam Books.
    Park, E. U., & Lee, M. (2009). Illness experience of women with breast cancer in Korea: Using feminist phenomenology. Journal of the Korean Academy of Adult Nursing, 21, 504-518.
    Park, G. J., & Lee, K. H. (2002). A structural model for depression in middle-aged women. Journal of Korean Women's Health, 8(1), 69-84.
    Park, S. M. (2008). The effect of middle-aged women's social support, life stresses, and self-esteem on depression (Master's thesis). Dong-A University: Busan, South Korea. Retrieved from
    Pinquart, M., Fröhlich, C., & Silbereisen, R. K. (2007). Change in psychological resources of younger and older cancer patients during chemotherapy. Psycho-Oncology, 16, 626-633. doi:10.1002/pon.1103
    Rabin, E. G., Heldt, E., Hirakata, V. N., Bittelbrunn, A. C., Chachamovich, E., & Fleck, M. P. (2009). Depression and perceptions of quality of life of breast cancer survivors and their male partners [Online exclusive]. Oncology Nursing Forum, 36, E153-E158. doi:10.1188/09.ONF.E153-E158
    Roesch, S. C., & Weiner, B. (2001). A meta-analytic review of coping with illness: Do causal attributions matter? Journal of Psychosomatic Research, 50, 205-219. doi:10.1016/S0022-3999(01)00188-X
    Rosenberg, M. (1965). Society and adolescent self-image. Princeton, NJ: Princeton University Press.
    Schroevers, M. J., Ranchor, A. V., & Sanderman, R. (2003). The role of social support and self-esteem in the presence and course of depressive symptoms: A comparison of cancer patients and individuals from the general population. Social Science and Medicine, 57, 375-385.
    Shin, K. R. (2001). Depression among Korean women. Journal of the Korean Academy of Nursing, 31, 391-400.
    So, W. K., Marsh, G., Ling, W. M., Leung, F. Y., Lo, J. C., Yeung, M., & Li, G. K. (2009). The symptom cluster of fatigue, pain, anxiety, and depression and the effect on the quality of life of women receiving treatment for breast cancer: A multicenter study [Online exclusive]. Oncology Nursing Forum, 36, E205-E214. doi:10.1188/09.ONF.E205-E214
    Spiegel, D., Sands, S., & Koopman, C. (1994). Pain and depression in patients with cancer. Cancer, 74, 2570-2578. doi:10.1002/1097-0142. (19941101)
    Sung, M. H. (2002). Self-reported climacteric symptoms, self concept, and depression in middle-aged women. Journal of the Korean Academy of Adult Nursing, 14, 102-113.
    Tae, Y. S., & Kim, M. Y. (2007). Correlation between depression and spiritual health in women with cancer. Journal of the Korean Oncology Nursing, 7, 169-178.
    Tae, Y. S., & Kim, M. Y. (2009). Influencing factors on hope among patients with breast cancer. Journal of the Korean Oncology Nursing, 9(2), 86-94.
    Taylor, S. E. (1983). Adjustment to threatening events: A theory of cognitive adaptation. American Psychologist, 38, 1161-1173.
    Taylor, S. E., & Brown, J. D. (1994). Positive illusion and well-being revisited: Separating fact from fiction. Psychological Bulletin, 116, 21-27.
    Taylor, S. E., Kemeny, M. E., Reed, G. M., Bower, J. E., & Gruenewald, T. L. (2000). Psychological resources, positive illusions, and health. American Psychologist, 55(1), 99-109.
    Wonghongkul, T., Moore, S. M., Musil, C., Schneider, S., & Deimling, G. (2000). The influence of uncertainty in illness, stress appraisal, and hope on coping in survivors of breast cancer. Cancer Nursing, 23, 422-429.
    Youn, S. J. (2004). The effects of a forgiveness nursing intervention program on forgiveness and mental health in patients with advanced female cancer (Doctoral dissertation). Kosi University: Busan, South Korea. Retrieved from
    Zung, W. K. (1965). A self-rating depression scale. Archives of General Psychiatry, 12(1), 63-70.