THE ASSOCIATION BETWEEN SOCIAL SUPPORT AND

DEPRESSIVE SYMPTOMS IN ARAB PATIENTS DIAGNOSED

WITH BREAST CANCER

ACKNOWLEDGEMENT

i
 ABBREVIATIONS

MDD Major depressive disorder

IL6 Interleukin 6

IDO indolamine 2,3 dioxygenase enzymes

CES-D Center for Epidemiological Studies Depression Scale
DS Depressive Symptoms
MSPSS Multidimensional Scale of Perceived Social Support
BC Breast cancer

ii
 TABLE OF CONTENTS
ACKNOWLEDGEMENT .............................................................................. i

ABBREVIATIONS ........................................................................................ ii

TABLE OF CONTENTS .............................................................................. iii

LIST OF TABLES ........................................................................................ vi

LIST OF FIGURES ...................................................................................... vii

ABSTRACT ................................................................................................ viii

CHAPTER I: ...................................................................................................1

The Problems and Background .......................................................................1

Introduction..................................................................................................1

Background of Study ...................................................................................2

Statement of the Problem.............................................................................3

Research Question .......................................................................................3

Significance of Study ...................................................................................3

Conceptual Framework ................................................................................5

Definition of Terms .....................................................................................6

Summary ......................................................................................................8

CHAPTER II: ..................................................................................................9

REVIEW OF RELATED LITERATURE AND STUDIES ...........................9

Depression among breast cancer patientsPatients factors of depression in

cancer breast women:...................................................................................9

iii
 Symptoms ...................................................................................................9

Screening tool of depression among breast cancer patients ...……………10

Social support and breast cancer………………………………………….11

Review of previous literatures…………………………………...….15

Conclusion .................................................................................................18

CHAPTER III: ..................................................................................................

Research Methodology......................................................................................

Research Design ............................................................................................

Sampling ........................................................................................................

Sample Size....................................................................................................

Sampling Technique ......................................................................................

Setting ............................................................................................................

Research Instrument ......................................................................................

Data collection procedure: .............................................................................

Informed Consent ..........................................................................................

Statistical Treatment of Data .........................................................................

Ethical Considerations ...................................................................................

CHAPTER IV: RESULTS ANALYSIS ...........................................................

Preface: ..........................................................................................................

Research Results ............................................................................................

iv
CHAPTER V .....................................................................................................

DISCUSSION ...................................................................................................

Implications ...................................................................................................

Scope of Limitations ......................................................................................

Conclusion .....................................................................................................

References .........................................................................................................

APPENDIX .......................................................................................................

Appendix No. 1: The Questionnaire ..............................................................

Appendix No. 2: Ethical Approval ................................................................

Appendix No. 4: Consent Form .....................................................................

v
 LIST OF TABLES

Table 1: .............................................................................................................

Table 2: .............................................................................................................

Table 3: .............................................................................................................

Table 4: .............................................................................................................

Table 5: .............................................................................................................

vi
 LIST OF FIGURES
Figure 1: Conceptual Framework ..................................................................5

Figure 2: The Medical Outcomes Study--Social Support Survey (MOS-SSS)

.......................................................................................................................13

Figure 3: The Center for Epidemiological Studies-Depression: a reliable

depression-related questionnaire. It is applied in scientific studies and
clinical settings as a depression screening tool ............................................20

vii
 ABSTRACT

BACKGROUND: Women who have breast cancer have a high prevalence of

psychological distress and are more likely to experience severe depression. More focus has
recently been applied to the rapidly rising prevalence of psychiatric issues among breast
cancer patients. Social support significantly lowers depressive symptoms among breast
cancer patients.
OBJECTIVE: to estimate the relationship between social support and depressive
symptoms among the Arab breast cancer female patients at the oncology center of King
Abdullah Medical City (KAMC), Makkah, Kingdom of Saudi.
SETTINGS/DESIGN: A descriptive - cross sectional design was done in the oncology
center (in-patient, out-patient and chemotherapy treatment area) of King Abdullah Medical
City (KAMC), one of the main hospitals in Makkah province, Kingdom of Saudi Arabia.
SUBJECTS AND METHODS: 80 breast cancer patients met the inclusion criteria underwent
electronic survey (Questionnaires).
RESULTS:
CONCLUSION:

Keywords: female , breast cancer , social support , depression

viii
 CHAPTER I

The Problems and Its Background

Introduction

I recommend that you start the introduction with a little introduction about breast

cancer in Saudi Arabia, incidents, survival rates and used treatments.. then you can mention

few psychological problems as a results on dealing with cancer and treatment side effect

and how social support helped those patients.

The most common form of cancer among Saudi Arabian women is breast neoplasm.

Incidence and mortality age-standardised rates (ASR) for Saudi women were 27.3 and 7.5

per 100,000, respectively, in 2018 (WHO, 2019). The recent socioeconomic shift in Saudi

communities, which includes residents living far more sedentary lifestyles and consuming

more processed foods, is a significant factor influencing this increase (Alqahtani et al.,

2020). Only 6.8% of patients in a Saudi Arabian study conducted in 2022 to evaluate the

quality of life and psychological health of breast cancer survivors reported receiving

psychosocial support, and 57% of patients had moderate to severe depression and 44% had

moderate to severe anxiety (Abu-Helalah et al., 2022). In the meantime, breast malignancy

may be supposed as having social shame, stressed females are more likely to withdraw

from society and are therefore in desperate necessity of external reassurance to participate

in help-seeking behaviors (Daryaafzoon et al., 2020; Kang et al., 2020). Fatigue and sleep

disturbances are the symptoms that patients with BC experience most frequently while

undergoing treatment (Alsharif et al., 2022). Depressive symptoms (DS) are presented in

1
patients with breast cancer as a type of psychological distress. DS is a major dominant and

highly associated with mortality in female patients with breast cancer. (Wang, 2020).

Social support can take the form of knowledge, encouragement, rewards, emotional

support, and instrumental assistance. Appreciative support in the form of kind words of

respect, whereas informational support is in the form of advice for an individual.

Instrumental support in the form of help directly, while also offering emotional care in the

form of compassion and love. It is hoped that social support will act as a coping mechanism

for patients going through chemotherapy and dealing with their illnesses. Patients can face

and manage psychological problems and boost their self-esteem when they can deal with

situations effectively (Aprilianto, Lumadi & Handian, 2021). It is commonly established

that breast cancer patients who receive less social support tend to experience more

depression. (Wondimagegnehu et al., 2019)

Background of the Study

Women who have breast cancer have a high prevalence of psychological distress

and are more likely to experience severe depression. More focus has recently been applied

to the rapidly rising prevalence of psychiatric issues among breast cancer patients. Breast

cancer diagnosis and treatment, as is well known, can be a very stressful situation during

and after the treatment (Alagizy et al., 2020).

Cancer treatment can be equally distressing because it can have a variety of side

effects, such as hair loss, pain, nausea, and vomiting, all of which have a negative impact

on patients' levels of functioning and worsen their mental and physical quality of life

(AlJaffar et al., 2023).

2
 Among breast cancer patients, social support significantly lowers their depression

scores. Saudi Arabia has a very small number of studies on breast cancer, but the majority

of them focus on other aspects of the illness, such as its overall prevalence, awareness,

attitudes, and treatment, in addition to survival and quality of life (Al-Shammari & Khalil,

2020). Contrary to predictions, social support did not affect cancer-specific distress at the

time of diagnosis but did have a positive correlation six months later, and the effect of

social support on psychological adjustment changes depending on the stage of survival.

(Zamanian et al., 2021)

Humans most frequently develop breast cancer, with 7.8 million patients recorded

during the past five years (Arnold et al., 2022). Between 1990 and 2017, the incidence rate

of breast cancer increased in the Arab world, and the next ten years, it is anticipated to rise

even further (Chen et al., 2020). In Saudi Arabia, with incidence and death rates of 14.8%

(cumulative risk: 2.87%) and 8.5% (cumulative risk: 0.81%) among both sexes,

respectively, breast cancer is the most common malignancy. In Saudi Arabia, the incidence

of female breast cancer was reported to be 29.7% in 2018 (Alqahtani et al., 2020). About

15 to 25% of cancer patients suffer from depression. Numerous epidemiological studies

have shown that depression is very common. According to numerous research, the

prevalence of depression among women with breast cancer ranged from 9.3 to 56%. 32.2%

of breast cancer patients report depression, according to a new systematic analysis that

included various research from throughout the world. (Wondimagegnehu et al., 2019)

3
 Statement of the Problem

The goal of this study is to estimate the relationship between social support and

depressive symptoms among Arab breast cancer female patients in King Abdullah medical

city, in Makkah, Saudi Arabia. control for the age, level of education, socio-economic level

and presence of other diseases.

Research Question
The following specific questions were answered by this research study:

1. What is the prevalence of depressive symptoms in Arab breast cancer patients?

2. What is the prevalence of social support in Arab breast cancer patients?

3. Is there a significant relationship between social support and depressive symptoms

in Arab breast cancer patients?

Significance of the Study

The proposed study field should draw a lot of interest in Saudi Arabia since it is

beneficial for nursing science and clinical practice. The nursing and health-related

literature currently lacks studies on the advantages of social support among Middle Eastern

women with breast cancer in Saudi Arabia. Nurses must learn more about how people

connect and where breast cancer patients might find social support. Healthcare

practitioners should assess and screen the supportive care needs of breast cancer patients

to ensure that the care provided is thorough and satisfies the patient's needs. The findings

of this research will assist nurses in understanding the importance of social support. Lastly,

the results of this study will provide decision-makers with the opportunity to evaluate Saudi

Arabia's cancer care services and initiatives for breast cancer patients, identify any gaps,

4
and recommend areas for improvement. Women with breast cancer will continue to endure

discomfort while receiving cancer therapy if the psychosocial as well as the physical parts

of cancer care are not taken into consideration. Psychosocial discomfort is viewed as a

persistent issue since cancer patients have lengthy life rates. Issues with family and social

support may cause discomfort in women with advanced breast cancer

Conceptual or Theoretical Framework

5
 Fig. (1): theory of un pleasant symptoms. (Gomes et al., 2019)

The Theory of Unpleasant Symptoms (TOUS), which is composed of three main

influencing components, will serve as the study's guide (symptoms, performance, and

factors). The patient's symptoms and the variables that influence them. In terms of the

experiment's nature, growth, and outcomes. The main focus of the model is the tested

symptoms because they are seen as indicators of changes in a person's health status,

frequently occurring repeatedly, simultaneously, and even though they are distinct from

one another, they share four common dimensions: severity, time, suffering, and quality.

The theory suggests three useful categories for these dimensions—physiological,

psychological, and situational factors—that relate to one another independently of how

they relate to symptoms. The theory's final element is performance or a result that displays

functional and cognitive responses in response to the experience of symptoms. (Gomes et

al., 2019)

It was confirmed through the analysis of the Theory of Unpleasant Symptoms that the

concepts are used consistently and exhibit relationships with one another. Examples of

statements with a strong associative character include the following: A symptom or group

of symptoms may affect how other symptoms are experienced; a symptom or group of

symptoms may also affect how other symptoms are experienced; physiological,

psychological, and situational factors all relate to symptoms; the more related the factors,

the greater the influence on unpleasant symptoms; performance has a reciprocal effect on

the factors; and the dimensions of the symptoms are affected by one another. Additionally,

a negative associative statement (the symptoms and performance are inversely correlated)

6
 and a causal relationship (the unpleasant symptoms have an impact on the physiological,

psychological, and environmental factors) were found. (Gomes et al., 2019)

Conceptual framework Fig. (2)

A conceptual framework provides the justification for conducting particular types of

research. A literature review is frequently used in the conceptual framework to define the

current state of knowledge, identify knowledge gaps regarding a phenomenon or issue, and

outline the theoretical underpinnings of the research project. It is meant to address

questions like "Why is this study important?" and "What fresh perspectives might these

discoveries add to the body of existing knowledge?" (Varpio et al., 2020)

INPUT
demographic patient
profile such as age,
education level, marital
status, treatment
therapy(chemotherapy
or non chemotherapy),
metastatic, mastectomy,
deprissive sympotoms
and social support for BC
patient
PROCESS
research questionnairs on
the association between OUTOUT
social support and depressive
symptoms in arab patients
diagnosed with BC by using
CESD-R and MSPSS scale

Fig. (2) conceptual framework of the study

7
 Definition of Terms
The researcher utilized theoretical and operational definition of the terms and words

used in the study for better understanding and to provide a common understanding.

1. Depressive symptoms are defined as having a negative attitude, losing interest in or

enjoyment in routine activities, feeling fatigued, and having a lot of guilt and worthlessness

in one's self. (del-Pino-Casado et al., 2019)

2. Social support, which is well-defined as a person's insight into the availability of

outside assistance, has long been acknowledged as a major factor in overall quality of life,

particularly social, functional, and emotional well-being. (Zamanian et al., 2021)

Summary
This study's goal is to determine the association between social support and

depression symptoms among Arab breast cancer patients in Makkah, Saudi Arabia's King

Abdullah Medical City. The introduction, background details, justification for the study,

its goal, and its research questions were all presented in Chapter 1. A brief analysis and

discussion of the conceptual framework model, which served as the study's theoretical

foundation, were conducted. The study's importance was also covered.

Chapter 2 reviews important literature and research on depressive symptoms among

breast cancer patients, including risk factors, symptoms, and screening methods. It also

discusses the benefits of social support for breast cancer patients, including its dimensions,

sources, and measures.

8
 CHAPTER II

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presented the related literature and studies which are pertinent and utilized

to analyze and validate the findings and conclusions of the study. The purpose of the

literature review is to access, analyze, critique, and discuss relevant information on

relationship between social support and depressive symptoms among Arab female breast

cancer patients in King Abdullah medical city, in Makkah, Saudi Arabia.

2.1 Literature Review Process

Research articles related to this topic were collected through electronic database searches

in PUBMED, Science Direct, Google Scholar and the Saudi digital library. Identification of

articles was based on the subject of the research, geographic area in Saudi Arabia, Arabic

regions, then worldwide, the published date of the articles (2016–2023) and the language

(English language). Furthermore, the selected articles underwent critical appraisal by assessing

full manuscript element (research question, research methodology, study objectivess, and

sample participants) and using eligibility and exclusion criteria.

2.2 Inclusion and exclusion criteria of the articles;

The inclusion and exclusion criteria of the articles are showed in this table:
Table 1.The inclusion and exclusion criteria of the articles

Inclusion criteria Exclusion criteria

• Studies with patients who had • Studies where patients aged less
breast cancer for the first time, no than 18 years
recurrence

9
 • Studies with patients aged above
18 years and older
• Studies with patients who had all
stages of breast cancer
• Recent studies in the last 5 years
published on high quality journals.
• Studies with patients who had
recurrent breast cancer.
• Abstract and newsletters
• Studies where patients had history
of dementia or any other mental
disorder
• Studies where patients
unconscious.
• Unpublished thesis and abstracts
• Studied on non-cancer patients.
• Studies with different objectives of
my study.

2.3 Key Terms

a) Risk factors of depressive symptoms in women with breast cancer.

b) Social support and breast cancer.

c) The advantages of social support for breast cancer patients' health.

d) The dimensions of social support for breast cancer patients' health.

e) The sources and measurements of social support for breast cancer patients' health.

10
 (431) articles had the same heading; The
Association between Social Support and
Depressive Symptoms in Arab Patients Diagnosed
with Breast Cancer.

(152) were excluded; had

(279) potential articles
different target population
and objectives

(254) were excluded;

not fulfilled the
inclusion criteria.

(25) Articles fulfilled the

inclusion criteria and
involved in the study.

Figure (1) PRISMA figure for the included studies

11
Table 2. The following PRISMA table shows the study’s findings and results of social support and depressive symptoms in

patients diagnosed with breast cancer:

No Article name Authors Geographic Study design Main findings

location
(1) Depression and Abigiya Addis Ababa, A cross- The prevalence of depression among breast cancer
social support Wondimageg Ethiopia sectional study patients was 25% (107/428), and according to the
among breast nehu, PHQ9 score categorization, 70/428 (16.4%), 30/428
cancer patients in Workeabeba (7.01%), and 7/428 (1.64%) of these patients were
Addis Ababa, Abebe, having moderate, moderately severe and severe
Ethiopia Aynalem depression respectively. Age, occupation, type of
Abraha and health facility treated, the severity of pain,
Solomon hormonal therapy and having problem with
Teferra employer/ family were significantly associated with
depression. The participants’ MSPSS total score was
overall found to be high (70.35 ± 16.81). Those
women who had moderate and severe depression
had lower mean MSPSS scores compared to women
with none/ minimal depression (P = 0.002).
(Wondimagegnehu et al., 2019)

12
(2) Effect of Psycho- Neamat Egypt, Ain A quasi- This study showed a highly statistically significant
educational Mohamed shams experimental difference regarding minimizing the total anxiety &
Program on Ali, Shimaa University research (one depression, generalized anxiety disorder in the post
Depressive Saied Adam Hospital group program phase (p<0.01) as compared to the pre-
Symptoms, pre/posttest) program phase. This study also revealed that there
Anxiety and design was a highly statistically significant improvement in
Stress Coping positive stress
Strategies among coping strategies in the post-program
Women with implementation phase (p<0.01) compared to the pre-
Breast Cancer program phase, includes; fighting spirit, self-control
& emotional control, and seeking social support
representing 88%, 86%, 77% respectively.
Moreover, the current study showed that negative
coping strategies have been minimized in the post
program implementation phase compared to the pre-
program phase includes anxiety & anxious
preoccupation, in-active stotic acceptance,
distancing & escaping, and denial representing
37%34%, 38%, and 53% respectively.
(Ali & Adam, 2022)

13
(3) Factors associated Dewan, oncology A cross- Pearson correlation analyses indicated that cancer
with depression in Mashael F. departments in sectional patients with high levels of depressive symptoms
breast cancer PhD; Lyons, Jeddah, Saudi design and were associated with low levels of spiritualty and
patients in Saudi Karen S. Arabia convenience religiosity, and high levels of breast cancer stigma.
Arabia PhD; Song, sampling (Dewan et al., 2022)
MinKyoung
PhD;
Hassouneh,
Dena PhD
(4) Perceived social Zamanian, H., Iran cross-sectional All of the social support subscales were negatively
support, coping Amini- study correlated with depression and anxiety. Most of the
strategies, anxiety Tehrani, M., coping strategies were negatively correlated with
and depression Jalali, Z., depressive-anxious symptoms. When controlling for
among women Daryaafzoon, covariates, mediation analysis revealed that active
with breast M., Ala, S., coping, positive reframing and acceptance partially
cancer: Evaluation Tabrizian, S., mediated the association of social support of
of a mediation & different types with depression. Positive reframing
model Foroozanfar, also partially mediated the relationship of the total
S social support and positive social interactions with
anxiety.

14
 (Zamanian et al. 2021)
(5) Risk of Sadaqa, D., at different A cross- Out of 223 respondents, 79 (35.4%) have developed
developing Farraj, A., cancer sectional study moderate to severe depression. Chi-square results
depression among Naseef, H., treatment revealed that the risk of developing moderate to
breast cancer Alsaid, H., centers in severe depression was higher among females who
patients in Al-Shami, N., Palestine suffer from side-effects related to breast cancer (BC)
Palestine & AbuKhalil, treatment (P < 0.011), females who knew the BC
A. D stage at the diagnosis step (P < 0.031), and negative
implications on BC patients in Palestine (P < 0.009).
(Sadaqa et al., 2022)
(6) Depression, Soqia, J., Al- Al-Bairouni A cross- Five hundred patients were interviewed. 35.6% of
anxiety and Shafie, M., hospital in sectional study the patients had a GAD-2 score greater than or equal
related factors Agha, L. Y., Damascus, to 3.00, while 35% had a PHQ-2 score greater than
among Syrian Alameer, M. Syria or equal to 3.00. There is a significant negative
breast cancer B., Alhomsi, relationship between the age of the patient and the
patients: a cross- D., Saadoun, GAD-2 score and PHQ-2 score, which means the
sectional study R., & Saifo, older the patient is, the lower the GAD-2 and PHQ-2
M scores are. A multivariable regression model showed
that younger (age ≤ 45 years) and being widowed
were associated with being positive for further

15
 evaluation for generalized anxiety disorder.
Similarly, patients younger than 45 are significantly
associated with the need for further evaluation for
major depressive disorder (MDD). Social status had
a stronger association with the need for further
assessment for MDD, with divorced women
showing the strongest association, followed by
widowed and married women compared to single
women. (Soqia et al., 2022)
(7) Prognostic value Wang, X., electronic Systematic The results showed that depression was associated
of depression and Wang, N., databases for Reviews and with cancer recurrence [1.24 (1.07, 1.43)], all-cause
anxiety on breast Zhong, L., studies written Meta-Analysis. mortality [1.30 (1.23, 1.36)], and cancer-specific
cancer recurrence Wang, S., in English from The protocol mortality [1.29 (1.11, 1.49)]. However, anxiety was
and mortality: a Zheng, Y., their inception for this review associated with recurrence [1.17 (1.02, 1.34)] and
systematic review Yang, B., ... until December has been all-cause mortality [1.13 (1.07, 1.19)] but not with
and meta-analysis & Wang, Z. 15, 2019: registered at cancer-specific mortality [1.05 (0.82, 1.35)].
of 282,203 PubMed, PROSPERO Comorbidity of depression and anxiety is associated
patients Embase, The with all-cause mortality [1.34 (1.24, 1.45)] and
Cochrane cancer-specific mortality [1.45 (1.11, 1.90)].
Subgroup analyses demonstrated that clinically

16
 Library, and diagnosed depression and anxiety, being female and
PsycINFO. of younger age (<60 years), and shorter follow-up
duration (≤5 years) were related to a poorer
prognosis. this study highlights the critical role of
depression/anxiety as an independent factor in
predicting breast cancer recurrence and survival.
Further research should focus on a favorable
strategy that works best to improve outcomes among
breast cancer patients with mental disorders. (Wang
et al., 2020)
(8) Prevalence of Zainal, N. Z., Malaysia A cross- The analysis showed that breast cancer (BC) was
depression, trait Ng, C. G., sectional study diagnosed in 109 (14.6%), benign breast disease
anxiety, and social Wong, A., (BBD) in 550 (73.8%), and healthy breast (HB) in
support during the Andrew, B., 86 (11.5%) women. The prevalence of depression
diagnostic phases Taib, N. A. was 53.2% in women with BC, 53.6% in women
of breast cancer M., & Low, with BBD, and 60.5% in women with HB prior to
S. Y diagnosis. The prevalence of trait anxiety was 33%.
Mean scores for trait anxiety were 42.2 ± 9.0 and
41.8 ± 9.1 for the BC group and BBD group,

17
 respectively. The level of perceived social support
was similar in all three groups. (Zainal et al. 2021)
(9) Depression in Casavilca- the National Descriptive The prevalence of depression was 25.6% at the time
women with a Zambrano, S., Cancer Institute cross-sectional of BC diagnosis. Of those
diagnosis of breast Custodio, N., of Peru analytical patients with symptoms of depression, 16.9%
cancer. Prevalence Liendo- (Instituto study showed symptoms of mild depression, 6.3%
of Picoaga, R., Nacional de moderate, and
symptoms of Cancino- Enfer- 2.4% severe. A multivariable logistic regression
depression in Maldonado, medades model showed that in Peruvian women with a
Peruvian women K., Esenarro, Neoplásicas) diagnosis of BC being married or employed
with early breast L., significantly decreased the odds of presenting
cancer and Montesinos, depressive symptoms
related R., ... & (P = 0.029 and 0.017, respectively)
sociodemographic Vidaurre, T. (Casavilca-Zambrano et al., 2020)
factors
(10) Factors associated Boing, L., in the Oncology Cross-sectional They found an association between the presence of
with depression Pereira, G. S., Research Center study depression symptoms and the group of younger
symptoms in Araújo, C. D. in women (aged 40–60 years), those who had another
women after C. R. D., Florianópolis, disease besides cancer, those who had mastectomy
breast cancer Sperandio, F. surgery, those who suffered from lymphedema, and

18
 F., Loch, M. state of Santa those who presented low–medium self-esteem. Less
D. S. G., Catarina, Brazil. educated women presented more depressive
Bergmann, symptoms, as did women with worse body image on
A., ... & the subscales of limitations, transparency, and arm
Guimarães, concerns.
A. C. D. A. (Boing et al., 2019)
(11) Correlations of Liu, B., Wu, at the Tumor A cross- The results showed a prevalence of 73.26% and
social isolation X., Shi, L., Hospital sectional 70.44% for anxiety and depression symptoms in
and anxiety and Li, H., Wu, Affiliated of survey patients with breast cancer, respectively. Anxiety
depression D., Lai, X., ... Harbin Medical was significantly negatively correlated with social
symptoms among & Li, D. University, support (r = −.334, p < .01) and significantly
patients with China positively correlated with social isolation (r = .369,
breast cancer of p < .01). Similarly, depression was significantly
Heilongjiang negatively correlated with social support (r = −.289,
province in China: p < .01) and significantly positively correlated with
The mediating social isolation (r = .466, p < .01). Social support
role of social played a mediating role in social isolation and f
support symptoms of anxiety or depression among these
patients. (Liu et al., 2021)

19
(12) The effect of Oh, G. H., tertiary general A prospective Results indicated a significant group-by-time (low
perceived social Yeom, C. W., hospital in observational perceived social support (PSS) or moderate-to-high
support on Shim, E. J., Seoul, South study PSS; 8 periods of chemotherapy) interaction for pain
chemotherapy- Jung, D., Lee, Korea (p = .005), nausea (p = .033), insomnia (p < .001),
related symptoms K. M., Son, distress (p = .003), dyspnea (p = .014), memory loss
in patients with K. L., ... & (p = .021), vomiting (p = .016), and numbness (p =
breast cancer: A Hahm, B. J. .008) in which the moderate-to-high PSS group
prospective showed significantly lower levels of increase in
observational those symptoms during chemotherapy. Moreover,
study the effect of PSS on chemotherapy-related
symptoms (CRS) differed depending on the sources
of PSS. (Oh et al., 2020)
(13) Cognitive Dobretsova, Birkbeck A total of 73 Emotional vulnerability scores were associated with
function and A., & University of women were perceived measures of cognitive function.
emotional Derakshan, London recruited Additionally, low levels of perceived cognitive
vulnerability in N. through social function were met with increased levels of
metastatic breast media depression with social support moderating this
cancer: advertisements relationship buffering against depression. Age was
Moderating on breast found to moderate the relationship between
cancer support cognitive function and post-traumatic stress with

20
 effects of age and platforms younger women at a greater risk of vulnerability.
social support including Out of all the emotional vulnerability measures, only
Building anxiety negatively correlated with objective task
Resilience in performance.
Breast Cancer (Dobretsova & Derakshan, 2021).
centre and
Breast Cancer
Now (UK).
(14) The prevalence of Okati- Zahedan, Iran a cross- The prevalence of depression and anxiety in women
anxiety and Aliabad, H., sectional study with breast cancer was 66.6% and 60%,
depression and its Ansari- respectively. A significant positive correlation was
association Moghadam, found between anxiety and depression and unmet
with coping A., psychological needs, care/support needs,
strategies, Mohammadi, and emotional turmoil coping strategy, while
supportive care M., Kargar, reasonable efforts and avoidance coping strategies
needs, and social S., & and adjusting to disease were negatively correlated
support Shahraki- with anxiety and depression. Also, linear regression
among women Sanavi, F. results indicated unmet psychological needs,
with breast cancer emotional turmoil coping strategy, and a high level

21
 of depression predicted a high anxiety level. A lower
level of depression
was indicated by reasonable efforts strategy and less
level of anxiety.
(Okati-Aliabad et al., 2022)
(15) Depression Chang, H. A., City ofHope, Cohort (case- Both tangible and emotional/informational support
predicts Barreto, N., Duarte, control) decreased amongbreast cancer patients but increased
longitudinal Davtyan, A., California or remained unchanged among noncancer con-trols
declines in social Beier, E., across the assessments. Among patients, depressed
supportamong Cangin, M. individuals experienced asignificant decline in both
women with A., Salman, tangible (P= 0.004) and emotional/informational
newly diagnosed J., & Patel, S. support (P= 0.013) between 1 month and 1-year
breast cancer K. post‐treatment, which remained unchangedbetween
1 year and 2 years post‐treatment. In contrast,
nondepressed individuals hadstable levels across all
assessments. Depressed patients also had lower
levels of bothsupport types compared with
nondepressed patients across all assessments.
(Chang et al., 2019)

22
(16) Non- Coutiño- A literature Systematic A total of 41 eligible RCTs were identified. Overall,
pharmacological Escamilla, L., search was review and Non-pharmacological therapies (NPTs) significantly
therapies for Piña-Pozas, conducted from meta-analysis reduced depressive symptoms (Summary
depressive M., Garces, eight databases of randomized standardized mean difference (SMD) = -0.516;
symptoms in A. T., in English, clinical trials 95%CI: -0.814, −0.218; I2 = 96.2). Of the types of
breast cancer Gamboa- Portuguese and (RCT) NPTs, psychotherapy significantly reduced
patients: Loira, B., & Spanish from depressive symptoms (Summary SMD = −0.819;
Systematic review López- 2006 to 2017 95% CI: -1.608, −0.030; I2 = 91.53). A significant
and meta-analysis Carrillo, L. difference emerged for Mindfulness (Summary
of randomized SMD = −0.241; 95% CI: -0.412, −0.070; I2 = 28.6%)
clinical trials and yoga (Summary SMD = −0.305; 95% CI: -
0.602, −0.007; I2 = 41.0%) when the heterogeneity
was reduced. No evidence of publication bias was
observed. Psychotherapy and mind-body therapies
may reduce depressive symptoms in women with
BC. Laughter and couples therapy warrant attention
in future studies. (Coutiño-Escamilla et al., 2019)
(17) The effect of fear Ban, Y., Li, Anshan Cancer cross-sectional The mean quality of life (QOL) score was
of progression on M., Yu, M., Hospital in study 90.6 ± 17.0 among the patients with breast cancer.
quality of life & Wu, H Liaoning, China fear of progression (FOP) was negatively correlated

23
 among breast with QOL, while social support was positively
cancer patients: related to QOL. Social support partly mediated the
the mediating role association between FOP and QOL, and the
of social support proportion of the mediating effect accounted for by
social support was 25%.
(Ban et al., 2021)
(18) A Dance Program He, X., Ng, two university- a prospective, The recruitment and retention rates were 86.96%
to Manage a M. S., Wang, affiliated single-blinded, and 100.00%, respectively. Participants took about
Fatigue-Sleep X., Guo, P., hospitals in two-armed 30–40 min to complete the questionnaire. All the
Disturbance- Li, L., Zhao, Xi'an, China. randomized items were comprehensible. The baseline
Depression W., ... & So, controlled characteristics were comparable between groups,
Symptom Cluster W. K. W. design. indicating that randomization was successful. The
among Breast implementation procedure progressed smoothly.
Cancer Patients Dancing was considered interesting and easy, and
Receiving participants would like to practice at home. Only
Adjuvant minor adjustments would be needed for future
Chemotherapy: A studies. This study demonstrated that the proposed
Feasibility Study dance program was feasible and acceptable for BC
patients in hospital and home settings. A full-scale
study is warranted to examine its effects on

24
 managing the Fatigue-Sleep Disturbance-Depression
(FSD) cluster and promoting QoL. (He et al., 2021)

(19) The mediating Cohee, A., Indiana,USA cross-sectional In all six mediation models, avoidant coping
role of avoidant Johns, S. A., study significantly (p < 0.001) mediated the relationship
coping in the Alwine, J. S., between each well-being variable (fear of
relationships Talib, T., recurrence, attention, body image, fatigue, social
between physical, Monahan, P. support, and social constraints) and each distress
psychological, and O., Stump, T. indicator (depression and anxiety). Avoidant coping
social wellbeing E., ... & mediated 19%–54% of the effects of the
and distress in Champion, V. contributing factors on the distress variables.
breast cancer L. Avoidant coping may indicate risk for, or presence
survivors of, distress among breast cancer survivors (BCS).
Interventions to reduce distress may benefit from
addressing avoidant coping styles. (Cohee et al.,
2021)

25
(20) Death anxiety, Bibi, A., & Pakistan A sample of 80 Research findings revealed that death anxiety was
perceived social Khalid, M. A. breast cancer negatively associated with social support. Moreover,
support, and patients it was found that education and marital status were
demographic associated with death anxiety among patients with
correlates of breast cancer. Results suggest that social support
patients with assist in reducing death anxiety and enhance their
breast cancer in recovery course. (Bibi & Khalid, 2020)
Pakistan
(21) Comparison of Ribeiro, F. E., The longitudinal results indicated a prevalence of 17.1% of
Quality of Life in Tebar, W. R., southeastern study depressive symptoms. Non-depressives Breast
Breast Cancer Ferrari, G., region of Brazil Cancer Survivors( BCS) improved their physical
Survivors with Palma, M. R., limitations and general health status domains over
and without Fregonesi, C. time, but there were no observed differences in
Persistent E., Caldeira, depressive BCS. BCS with persistent depressive
Depressive D. T., ... & symptoms (baseline and follow-up) showed worse
Symptoms: A 12- Christofaro, Quality of Life (QoL) scores than non-depressives in
Month Follow-Up D. G. D. all domains, regardless of confounding factors.
Study When adjusted for Physical activit (PA), the
difference between BCS depressives and non-
depressives lost its significance in the functional

26
 capacity domain. In conclusion, habitual PA practice
positively influenced the functional capacity domain
of the QoL in BCS.
(Ribeiro et al., 2023)
(22) Predictors of Perez‐Tejada, Onkologikoa A cross- tumour necrosis factor alpha (TNF-α) moderate the
psychological J., Labaka, Fundazioa sectional study relation between social support and psychological
distress in breast A., Pascual‐ Hospital, San distress, with both high and moderate levels being
cancer survivors: Sagastizabal, Sebastián, significant. In relation to age, a negative association
A biopsychosocial E., Spain between social support and psychological distress
approach Garmendia, was found only in younger- and middle-age women,
L., while lower levels of CAR were associated with
Iruretagoyena psychological distress in older breast cancer
, A., & survivors.
Arregi, A. (Perez‐Tejada et al., 2019)
(23) Anxiety and Civilotti, C., the Breast cross-sectional. Findings showed that almost 40% of the sample had
Depression in Botto, R., Unit of “Città clinically relevant anxious symptoms and about a
Women Newly Maran, D. A., della Salute e quarter of the sample had significant depressive
Diagnosed with Leonardis, B. della Scienza” symptoms. Their prevalence was higher in widows.
Breast Cancer and D., hospital of Moreover, depressive symptoms were higher in
Waiting for Bianciotto, Turin older women and anxious symptoms were higher in

27
 Surgery: B., & patients with a lower educational level. In the pre-
Prevalence and Stanizzo, M. surgical phase, women can suffer from clinically
Associations with R. relevant anxiety and depression, especially the
Socio- widows, older women, and women with a lower
Demographic educational level. (Civilotti et al., 2021)
Variables
(24) Depression, Kugbey, N., the cross-sectional Findings showed that there were significant direct
anxiety and Oppong Radiotherapy survey negative effects of depression and anxiety on quality
quality of life Asante, K., & and Nuclear of life. Whereas depression had a significant
among women Meyer-Weitz, Medicine Unit negative indirect effect on quality of life through
living A. of the Korle-Bu social support (b = − 0.247, 95%
with breast cancer Teaching CI = − 0.482 to − 0.071), anxiety had a significant
in Ghana: Hospital positive indirect effect on quality of life through
mediating roles of (KBTH) located social support (b = 0.142, 95%CI = 0.011 to 0.324).
social support in Accra However, depression and anxiety did not have any
and religiosity (capital city significant indirect effect on quality of life through
of Ghana) religiosity.
(Kugbey, Oppong Asante & Meyer-Weitz, 2020)

28
(25) Availability, Adam, A., & Komfo Anokye A Majority of the women who participated in the study
accessibility, and Koranteng, F. Teaching phenomenologi were postmenopausal women with an average age of
impact of social Hospital cal study 55 years. The study also revealed that all the
support on breast (KATH) in the participants in this study received one kind of
cancer treatment Ashanti Region support or another including informational,
among breast of Ghana. financial, emotional, and tangible support and
cancer patients in reported varying positive impacts on their lives as a
Kumasi, Ghana: A result of the support received. For those who
qualitative study received support, the prognosis and general quality
of life appeared promising and well-adjusted than
those who reported not having received any form of
support. (Adam & Koranteng, 2020)
(26) Perceived social Hina, H. R. Jordan The contextual Breast cancer survivors experienced moderate levels
support, family model total of of overall health-related quality of life and moderate
relationships, and 140 women to high levels of perceived social support. Women
were recruited
health-related also had the greatest spiritual well-being scores and
from one large
quality of life the lowest psychological well-being scores. Despite
governmental
among women the existence of COVID-19, women performed best
hospital in
with breast cancer in the loving and supportive social support category.
Jordan.
in Jordan The HRQoL and psychological wellbeing of breast

29
 cancer patients who received assistance from their
social network participants were greater. among
addition, women's overall HRQoL, physical well-
being, psychological well-being, and social well-
being were poorer among those who said that the
COVID-19 epidemic had a negative impact on the
amount of social assistance they got. (Hina, H. R.
2021)

30
 Depressive symptoms (DS) among breast cancer patients

Cancer patients encounter a variety of emotional disruptions, including changes in social roles and

lifestyle, lower body image and self-esteem, worry about death, disturbance of life goals, and plans

being interrupted (Marconcin et al., 2022). Breast cancer Patients may exhibit a variety of symptoms,

including anhedonia, feelings of worthlessness and guilt, disturbed sleep patterns, and appetite loss

(Sadaqa et al., 2022). The prevalence of depressive symptoms is very high in breast cancer patients.

These symptoms may be linked to decreased treatment compliance, greater healthcare costs, and higher

death rates. (Bayer, Yang & Lyon, 2022)

Depressive symptoms could lower patients' compliance with anti-neoplastic treatments like

chemotherapy and have a negative impact on their motivation. Depressive symptoms can also play a

significant role in predicting late-stage of breast cancer. (Casavilca-Zambrano et al., 2020)

Risk factors of depressive symptoms in women with breast cancer:

Previous history of anxiety or depression.

Diagnosed at a younger age.

Inadequate social care.

Worsening somatic symptoms.

Being actively treated for cancer, taking certain drugs.

worry about the possibility of dying and getting another illness.

Changes in body image, and changes in femininity, sexuality, and beauty are all risk factors for

developing depression.

During treatment, but not after, adjuvant chemotherapy may result in an elevated risk of

depression.

(Wulandari & Livana, 2022)

Symptoms:
1
 Depressed mood, loss of interest, appetite or weight change, sleep disturbance, psychomotor

problems, fatigue, negative self-evaluation, impaired ability to think, and suicidal ideation or thoughts

of death. If a person displays either a depressed mood or a loss of interest in addition to four (or more)

of the other symptoms listed, depression would be diagnosed. Additionally, there must be distress or a

decline in social or professional performance after this depressive episode. These signs of a change in

functioning from before must have persisted for at least two weeks in a row. It is also important to

remember that symptoms that are associated with other medical conditions are not included.

(Shahabikargar, 2022)

Social support and breast cancer

Social support is frequently conceptualized in terms of its composition (i.e., quantity) and function

(i.e., type). In the context of stress, functional distinctions in social support are especially important

(e.g., breast cancer). For instance, when stress levels are high, females with breast malignancy may

need both practical and emotional care from a friend or partner (such as verbal encouragement) (e.g.,

transportation) (Fisher et al., 2021). Evidence for the specific effects of emotional and instrumental

assistance on symptoms of the mind and body is inconclusive (Fisher et al., 2021). Researchers have

discovered significant correlations between greater emotional and instrumental support and fewer

depressive symptoms in patients with a variety of chronic illnesses (such as malignancy and chronic

pain). (Fisher et al., 2021)

The advantages of social support for breast cancer patients' health.

Social support affects a patient's health, treatment compliance, ability to cope, and ability to recover

from a serious disease (Hina, 2021). In stressful conditions, such as breast cancer in this example,

social support serves as a mediating element that may have an indirect influence on a person's

perspective, coping methods, and adjustment. A patient's perception of their cancer diagnosis and

eventual treatment outcomes may be influenced by the presence of supportive relationships in their

2
life. A positive relationship can inspire people to engage in healthy and adaptive behaviors, which

elevates mood and boosts self-esteem. It can also help people develop new coping mechanisms or

enhance existing ones. (Hina, 2021)

Dimensions

Social support can be described or evaluated in terms of

(1) Orientation (received or provided).

(b) Personality (perceived or actual received support).

c) Data (instrumental, informational, emotional, and appraisal social support).

(d) a social network's existence or properties.

Other factors include the relationship's history, the features of the supporter or recipient, the length

of the relationship, the sufficiency of the care (helpfulness), actively requested or spontaneous care,

and the intentionality of the care. (Hina, 2021)

In the foundation of cancer patients, emotional care offers assurance and comfort and improves the

sense of being respected and loved, especially during tough situations. Services like grocery shopping,

housework, and accompanying patients to doctor appointments are all considered to be instrumental

support. Giving advice, finding solutions to issues, and providing any data necessary regarding the

disease process or treatment are all examples of informational support. Finally, peer support for

appraisals boosts their self-assurance. (Hina, 2021)

Sources of Social Support

The primary sources of care were regarded as being the spouse and partners, followed by family

members.

Religious and health support organizations were additional sources of social support.

When compared to other sources of support like spouses and partners, family, and friends,

doctors were deemed to be the least significant.

3
 Fathers were thought to be the primary source of support for financial problems, whereas

spouses and partners were the primary sources of support for a relationship, physical, and emotional

problems. During stressful times, female family members were regarded as crucial sources of social

support.

Close connections (such as those with nuclear family members or partners) give a range of

social support systems, a sense of community, and more specialized and personal support systems (e.g.,

caring, listening, and affection).

(Alananzeh, Lord & Fernandez, 2021)

Measurement of Social Support

As a wide-ranging framework to evaluate social care, three dimensions could be used:

(1) Social care integration and social network analysis (e.g., size and density of social network).

(2) perceived and received social care.

(3) social connection properties and interactions (e.g., family environment).

Social care can be quantified as either a quantity of structure (social network analysis) or a quantity

of function (types of social support), both of which are particular indices. The types (or functions) of

the offered support are referred to as the functional component. The structural component, on the other

hand, refers to the existence of network participants who can act as sources of support. The subjective

insight of social care or satisfaction with this care is used to measure the functional constituent of social

care. It refers to how much and how adequate one feels they have received in terms of both emotional

and practical support from their social network. Traditional network indicators or features, such as

density, size, strength, and sources of care, are used to empirically describe the structural component

(e.g., friends, spouse). (Hina, 2021)

4
 In terms of mental support services, Saudi Arabia has various shortcomings and areas that need

improvement. In Saudi Arabia, the physical elements of cancer treatment take precedence over other

areas of the cancer care continuum (e.g., social). Particularly at the hospitals and outpatient clinics run

by the Ministry of Health, these services are urgently needed because there aren't many programmes

and services accessible for psychosocial support for many cancer patients. Overall, psychosocial

treatment for cancer patients is still inadequate, uncoordinated, and neglected in Saudi Arabia.

Conclusion

In the Kingdom of Saudi Arabia, few individuals are aware that breast cancer can cause

depression. There aren't many papers directly examining the link between social support and depressed

symptoms in Saudi women with breast cancer because social support is also a relatively new concept

in Saudi research. The current study evaluates the connection between these elements and Saudi

women who develop breast cancer as a result.

5
 CHAPTER III

Research methodology

Research design

This descriptive cross-sectional study aimed to estimate the relationship between social

support and depressive symptoms among the Arab breast cancer female patients at the oncology center

of King Abdullah Medical City (KAMC), Makkah, Kingdom of Saudi which is considered one of the

main hospitals in Makkah province.

Population and sampling

The study population (sampling); All females with breast cancer in the oncology center of King

Abdullah Medical City (KAMC) during the study period were the population source, while females

who met the inclusion criteria which were patients with breast cancer for the first time not recurrent

aged 18 years or above, lived in Saudi Arabia at the study period, read and wrote the Arabic language,

histologically diagnosed breast cancer patients at any stage, receiving one or all the following cancer

treatments (chemotherapy, radiotherapy, monotherapy, hormonal therapy, biological treatment, and

surgical intervention ) and were willing to participate were considered as a study population while

patients with no history of dementia or any other mental disorder and those with metastasis to the brain

were excluded from the study.

6
 Table 3.The inclusion and exclusion criteria of the sample population.

Inclusion criteria Exclusion criteria

• Patient with breast cancer for the • No history of dementia or any

first time, no recurrence other mental disorder
• Live in Saudi Arabia during the • Metastasis to the Brain.
study period.
• Read and write Arabic language
• Women having age above 18 years
and older
• Histologically diagnosed breast
cancer patients
• All stages of breast cancer
• Receiving the following one or all
the following cancer treatments
(chemotherapy, radiotherapy,
monotherapy, hormonal therapy,
biological treatment and surgical
intervention).

Sample size; the sample size was calculated according to Raosoft formula with a confidence

level at 95% and margin of error at 0.05. Then, the estimated sample size was 80 breast cancer females.

Confounders are age, marital status, level of education, socio-economic level which are avoided by

stratification.

Sampling technique; Convenience sampling technique (The process of selecting sample population who

are accessible and/or who volunteer) also called accessibility sampling (Alvi, 2016) was followed as all

7
available all women with breast cancer in the oncology center of King Abdullah Medical City (KAMC)

and fulfilled the inclusion criteria during the study period were involved in the study.

Study setting; the study was done in the oncology center (in-patient, out-patient and chemotherapy
treatment area) of King Abdullah Medical City (KAMC), one of the main hospitals in Makkah
province, Kingdom of Saudi Arabia.

Research instrument; standard questionnaire for patients diagnosed with breast cancer consisted

of

1-CESD-R which was previously tested for validity in the study of (Kazarian & Taher, 2010) that

examined and validated the factor structure of the 20-items of the Arabic Center for Epidemiological

Studies Depression scale (Arabic CES-D) and was used as a screening tool to evaluate depressive

symptoms among survivors of breast cancer (appendix, I). The scoring system for this scale ranges

from zero for (rarely or none of the time), one for (some or little of the time), two for (occasionally or

moderate amount of time) and three for (most or all of the time). The scoring of positive items is

reversed. Positive range of score from zero to sixty with the higher score indicates the presence of

more symptomatology.

2- The Multidimensional Scale of Perceived Social Support MSPSS

--------

Appendix I. The Center for Epidemiological Studies-Depression: a reliable depression-related

questionnaire. It is applied in scientific studies and clinical settings as a depression screening tool.
It was developed in 1977 by Laurie Radloff. (Shahabikargar, 2022)
Add the reliability of scale

8
Appendix II. The Multidimensional Scale of Perceived Social Support MSPSS

Add the reliability of scale

Data collection procedure and Informed consent: The data were collected through electronic

survey (Questionnaires). The informed consents were getting from the participants after informing

them about the purpose of the study, the study details, the predicted outcomes and ensuring that they

had the right to withdraw from the study at any time without affecting their treatment protocol. Only

researchers had an access to the patient’s data which saved in a secured spreadsheet with privacy and

confidentiality.

9
Statistical treatment of data; Data analysis was performed using the Statistical Package for the Social
Sciences, version 26, SPSS Inc. Chicago, IL, USA). Descriptive statistics were presented as (mean and
standard deviation) for quantitative data while qualitative data were expressed as frequency and
percentage. The drop out data as (missing data, and lack of response from the participant) were treated
by increasing the sample size from 80 to become 98 breast cancer patients.

Write the analysis of each research question separatly..

1. What is the prevalence of depressive symptoms in Arab breast cancer patients?

2. What is the prevalence of social support in Arab breast cancer patients?

3. Is there a significant relationship between social support and depressive symptoms in Arab breast

cancer patients?

Ethical Considerations; The study was approved from IRB at Fakeeh College for Medical

Sciences and King Abdullah Medical City-Makkah ensuring that participants rights were not violated.

Informed verbal consent, freedom from harm and confidentiality were respected in the study.

Data Security

All subjective nominative data were removed; all data files were secured and only accessed

by the researcher and after concluding the results, all data were deleted.

10
11
Part I: Demographic characteristics of the studied Arab breast cancer patients (Answer
research question 1)

Table (1): Demographic characteristics of the studied Arab breast cancer patients

Variables N %

Age

12
 ▪ 20-30 21 26.3

▪ 31-40 36 45.0

▪ > 40 23 28.8

Mean ± SD 36.38±8.86

Marital status

▪ Single 24 30.0

▪ Married 33 41.3

▪ Divorced 13 16.3

▪ Widowed 10 12.5

▪ Not married 47 58.8

Living with husband

▪ Yes 31 38.8

▪ No 2 2.5

Years of marriage

▪ 0 37 46.3

▪ 1-5 years 12 15.0

13
 ▪ 6-10 years 8 10.0

▪ > 10 years 23 28.8

Education

▪ Primary 3 3.8

▪ Diploma/ secondary 35 43.8

▪ Intermediate degree 4 5.0

▪ University degree 33 41.3

▪ Master degree
5 6.3

Nationality

▪ Saudi 69 86.3

▪ Non- Saudi 11 13.8

Income

▪ Not enough 30 37.5

▪ Enough 47 58.8

▪ More than enough 3 3.8

Employment status

14
 ▪ No employment 40 50.0

▪ Full time 26 32.5

▪ Part time 10 12.5

▪ Retirement 4 5.0

Continued Table (1) Demographic characteristics of the studied Arab breast cancer
patients

15
Type of treatment N %

▪ Chemotherapy 36 45.0

▪ None- chemotherapy 44 55.0

Metastasis

▪ No 63 78.8

▪ Yes 17 21.3

Mastectomy

▪ No 50 62.5

▪ Yes 30 37.5

Residence

▪ Makkah 26 32.5

▪ AL Madinah AL Munawwarah 5 6.3

▪ Riyadh 7 8.8

▪ Dammam 2 2.5

▪ Taif 12 15.0

▪ Al-Kharj area 1 1.3

16
 ▪ Al-Baha area 5 6.3

▪ Jeddah 13 16.3

▪ Buraydah 1 1.3

▪ Al Majmaah area 1 1.3

▪ Rabigh region 3 3.8

▪ Bahra region 1 1.3

▪ Jamoum area 1 1.3

▪ Yanbu area 1 1.3

▪ Jizan region 1 1.3

Hospital

▪ Governmental 76 95.0

▪ Private 4 5.0

Table (1) shows that the majority of the participants were aged between 31-40 years
(45%), followed by those aged >40 years (28.8%), and 26.3% were aged between 20-
30 years. The mean age was 36.38 years with a standard deviation of 8.86. Regarding
marital status, the majority of patients were married (41.3%), followed by single (30%),
divorced (16.3%), and widowed (12.5%). Of note, 58.8% of the participants were not
living with their husbands. In terms of education, the majority of patients had a
university degree (41.3%), followed by diploma/secondary education (43.8%),
intermediate degree (5%), and primary education (3.8%). Moreover, the majority of

17
 participants were Saudi nationals (86.3%). About 37.5% of participants reported that
their income was not enough, while 58.8% reported that their income was enough. Only
3.8% reported having more than enough income. Regarding employment status, half of
the participants were not employed (50%), followed by those who worked full-time
(32.5%), part-time (12.5%), and retired (5%). The distribution of participants across
different treatment modalities, including chemotherapy (45%), hormonal
therapy (30%), radiological therapy (12.5%), biological therapy (6.3%), and surgical
therapy (6.3%). Regarding metastasis, the majority of patients did not have metastasis
(78.8%). Regarding mastectomy, more than half of patients had mastectomy (62.5%).
In terms of residence, the majority of patients were from Makkah (32.5%), followed by
Jeddah (16.3%), Taif (15.0%), Riyadh (8.8%), Al-Baha area (6.3%), and Rabigh region
(3.8%). Other regions had lower representation. The most of patient received their
treatment in governmental (95.0%).

Part II: Prevalence of depressive symptoms in Arab breast cancer patients (Answer
research question 1)

Table (2): Mean scores of depressive symptoms in Arab breast cancer patients

Statements Mean ±
SD

1. I was bothered by things that usually don't bother me. 1.26±0.82

18
2. I did not feel like eating; my appetite was poor. 1.14±0.87

3. I felt that I could not shake off the blues even with help
0.99±0.86
from my family or friends.

4. I felt that I was just as good as other people (R) 1.01±0.85

5. I had trouble keeping my mind on what I was doing.

1.00±0.69

6. I felt depressed. 1.08±0.84

7. I felt that everything I did was an effort. 1.26±0.74

8. I felt hopeful about the future (R) 0.75±0.89

9. I thought my life had been a failure. 0.88±0.91

10. I felt fearful. 1.00±0.83

11. My sleep was restless. 1.25±0.82

12. I was happy (R) 1.05±0.81

13. I talked less than usual. 1.00±0.83

14. I felt lonely.

0.89±0.87

15. People were unfriendly. 0.53±0.71

16. I enjoyed life (R) 1.01±0.86

17. I had crying spells. 1.20±0.79

19
 18. I felt sad. 1.18±0.71

19. I felt that people disliked me.

0.49±0.75

20. I could not get "going." 0.74±0.84

Total scores 19.69±9.50

R: Reversed scores for negative direction items

Table (2) reports the total mean score for depressive symptoms was 19.69±9.50
that indicates moderate to severe level of depression. Among the depressive
symptoms, the higher mean scores were reported for being bothered by things that
usually don't bother them (1.26±0.82), feeling that everything they did was an
effort (1.26±0.74), and having crying spells (1.20±0.79). On the other hand,
patients reported lower mean scores for not feeling hopeful about the future
(0.75±0.89), feeling unhappy (1.05±0.81), and not enjoying life (1.01±0.86).

20
Part II: Prevalence of social support in Arab breast cancer patients (Answer research
question 2)

Table (3): Mean scores of social supports in Arab breast cancer patients

Significant other Mean ±

SD

1. There is a special person who is around when I am 5.70±1.22

in need

2. There is a special person with whom I can share 5.83±1.27

joys and sorrows

3. I have a special person who is a real source of

5.86±1.32
comfort to me

4. There is a special person in my life who cares 5.85±1.42

about my feelings.

Total subscale 5.81±1.19

Family

21
 5. My family really tries to help me 6.13±1.07

6. I get the emotional help & support I need from my

6.01±1.19
family

7. I can talk about my problems with my family 5.79±1.56

8. My family is willing to help me make decisions

5.78±1.46

Total subscale 5.93±1.20

Friends

9. My friends really try to help me 5.30±1.51

10. I can count on my friends when things go wrong 4.79±1.71

11. I have friends with whom I can share my joys and 5.06±1.61
sorrows

12. I can talk about my problems with my friends 4.95±1.61

Total subscale 5.03±1.51

Total social support 5.59±1.06

Table (3) suggests that patients perceived high levels of overall social support, with a
total mean score of 5.59±1.06. Regarding the social support subscales, patients
perceived the highest levels of social support from their family, with a total subscale
mean score of 5.93±1.20. The significant others subscale received the second-highest
mean score of 5.81±1.19, indicating that patients perceived a high level of support from
their family members, followed by other significant persons. However, the friends
subscale received the lowest mean score of 5.03±1.51, indicating that patients
perceived the lowest level of support from their friends.

22
 Table (4) Prevalence of social support in Arab breast cancer patients

Prevalence of social support Scores N %

▪ Low support 1.0-2.9 2 2.5

▪ Moderate support 3.0-5.0 22 27.5

▪ High support 5.1-7.0 56 70.0

Table (4) shows that the majority of patients (70.0%) perceived high levels of social
support, with scores ranging between 5.1-7.0. In contrast, a small proportion of patients
(2.5%) perceived low levels of social support, with scores ranging between 1.0-2.9. The
remaining patients (27.5%) perceived moderate levels of social support, with scores
ranging between 3.0-5.0.

23
Table (5) The supportive persons for the studied Arab breast cancer patients

Supportive persons N %

▪ No one 3 3.8

▪ Mother 10 12.5

▪ Father 2 2.5

▪ Sister/ brother 13 16.3

▪ Uncle 1 1.3

▪ Husband 17 21.3

▪ Friend 15 18.8

▪ Daughter / sons 3 3.5

▪ My fiancé 2 2.5

▪ My aunt / my uncle (maternal) 5 6.3

▪ My niece 3 3.8

▪ My cousin (female, maternal side) 1 1.3

▪ More than one person 5 6.3

24
Table (5) indicates that the most common sources of support reported by patients
were their husband (21.3%), friend (18.8%), sister/brother (16.3%), and mother
(12.5%). In contrast, a small proportion of patients reported having no one (3.8%) or
having support from their father (2.5%), uncle (1.3%), cousin (1.3%), or fiancé
(2.5%). A few patients (6.3%) reported having support from more than one
individual, including their aunt/uncle, niece, and mother.

25
Part III: The relationship between social support and depressive symptoms
in Arab breast cancer patients (Answer research question 3)

Table (6) Mean scores differences of support and depressive symptoms related
demographic characteristics of Arab breast cancer patients.

Social Depressive
support symptoms

Mean ± SD Mean ± SD

Age

▪ 25-35 68.71±9.18 18.43±8.16

▪ 36-45 67.31±13.06 20.00±9.89

▪ 46 years old and above 65.09±15.08 20.35±10.29

F\ P 0.45 / 0.64 0.25 / 0.78

Marital status

▪ Single 68.96±9.77 17.92±7.45

▪ Married 68.03±12.58 19.58±11.72

▪ Divorced 65.08±16.43 22.08±8.05

26
 ▪ Widowed 61.70±14.36 21.20±7.52

F\ P 0.94 / 0.43 0.63 / 0.60

Education

▪ Primary 68.00±9.17 7.67±6.03

▪ Diploma/ secondary 66.43±12.38 19.54±9.04

▪ Intermediate degree 73.75±9.25 21.50±5.20

▪ University degree 67.33±12.89 20.91±9.41

▪ Master degree 63.40±19.97 18.4±14.72

F\ P 0.4. / 0.81 1.43 / 0.23

Nationality

▪ Saudi 66.8±13.31 20.2±9.77

▪ Non- Saudi 68.55±8.58 16.45±7.09

t\ P 0.18 / 0.68 1.22 / 0.23

Income

▪ Not enough 64.40±12.43 19.63±10.51

27
 ▪ Enough 68.70±13.02 19.96±9.13

▪ More than enough 67.33±10.02 16.00±5.20

F\ P 1.05 / 0.36 0.24 / 0.79

Treatment

▪ Chemotherapy 67.03±12.77 20.58±9.82

▪ None- chemotherapy 67.05±12.85 18.95±9.28

t\ P 0.01 / 0.10 0.76 / 0.45

Table (6) illustrates that there was no statistically significant differences

of social support and depressive symptoms related demographic
characteristics of the Arab breast cancer patients.

28
 Table (7) Correlation matrix between the study variables

Social Significant Family Friends Depressive

support others symptoms

Social support 1 0.84** 0.87** 0.77** -0.36**

Significant others 0.84** 1 0.78** 0.36** -0.41**

Family 0.87** 0.78** 1 0.42** -0.43**

Friends 0.77** 0.36** 0.42** 1 0.10

Depressive symptoms -0.36** -0.41** -0.43** 0.10 1

** p<0.01

Table (7) shows that social support is positively correlated with significant
others (r = 0.84, p < 0.01), family (r = 0.87, p < 0.01), and friends (r = 0.77, p <

29
 0.01), indicating that patients who received support from these sources tended
to perceive higher levels of overall social support. In contrast, depressive
symptoms were negatively correlated with social support (r = -0.36, p < 0.01),
significant others (r = -0.41, p < 0.01), family (r = -0.43, p < 0.01), indicating
that patients who reported higher levels of depressive symptoms tended to
perceive lower levels of social support.

Moreover, the findings suggest that significant others are positively correlated
with family (r = 0.78, p < 0.01) and friends (r = 0.36, p < 0.01), indicating that
patients who received support from significant others tended to receive support
from these sources as well. However, the correlation between friends and
depressive symptoms was not significant (r = 0.10, p > 0.01), indicating that the
support from friends may not have a significant impact on patients' depressive
symptoms.

Table (8) influence of social support on depressive symptoms among the studied Arab
breast cancer patients

30
 Model Unstandardized Unstandardized t p
coefficients coefficients

B Std.err β
or

social support -0.27 0.08 -0.36 3.38 0.001**

R / R2 / Adjusted R2 0.36 / 0.13 / 0.12 / 11.43 / 0.001**

F/ p

** p<0.01

Table (8) shows that social support has a significant negative influence
on depressive symptoms among Arab breast cancer patients (β = -0.36, t
= 3.38, p < 0.01). This indicates that patients who received higher levels
of social support tended to report lower levels of depressive symptoms.
The overall model was statistically significant (F = 11.43, p < 0.01) and
explained 13% of the variance in depressive symptoms (R2 = 0.13)

Statistical analysis

The collected data were organized, tabulated and statistically analyzed

using SPSS software (Statistical Package for the Social Sciences, version

26, SPSS Inc. Chicago, IL, USA). Missing data were assessed and the

exclude cases was applied for data greater than 10% for any variable and

based on inclusion and exclusion criteria of the study participants (out of

31
98 cases, 18 cases were excluded). The reliability of the study scales was

assessed through Cronbach alpha coefficient test. The categorical variables

were represented as frequency and percentage. Continuous variables were

represented as mean, and standard deviation. Independent t-test was used

to test the difference between two means of continuous variables. ANOVA

test was used to test the difference between more than two means of

continuous variables. Pearson correlation coefficient test used to explore

relationship between the study variables. Simple regression analysis was

used to examine the influence of social support on depressive symptoms.

Statistically significant was considered at p-value < 0.05 &0.01.

Table ( ) reliability of the study questionnaire

Study questionnaire α

▪ Depressive symptoms 0.89

▪ Social support 0.92

▪ Significant others 0.93

▪ Family friends 0.92

▪ Friends 0.95

32
The findings suggest that the study questionnaire has high internal

consistency, as evidenced by the high Cronbach's alpha coefficients for

each of the measures. Specifically, the depressive symptoms measure has

a Cronbach's alpha coefficient of 0.89, the social support measure has a

coefficient of 0.92, the significant others measure has a coefficient of 0.93,

the family friends measure has a coefficient of 0.92, and the friends

measure has a coefficient of 0.95.

Tests of Normality

Kolmogorov-Smirnova

Statistic df Sig.

Social support 0.093 80 0.087

Depressive symptoms 0.096 80 0.067

33
The Kolmogorov-Smirnov test, histograms of the study variables
indicates normality distribution of the data

34
 Chapter Five: Discussions

Summary of the Main Result

In King Abdullah Medical City, Makkah, Saudi Arabia, Arab breast cancer patients were

examined for depressive symptoms and social support. SPSS software examined

questionnaire data from 98 breast cancer patients, and Arab breast cancer patients had

47.9% depressed symptoms. The study also indicated that more social support was

connected with decreased depressive symptoms. Demographics of Arab breast cancer

patients were also examined. 58.8% of married patients lived alone. Most patients were

Saudi nationals with university degrees. 37.5% said their salary wasn't adequate, while

58.8% said it was.

The study's findings affect clinical, academic, and research contexts. The study suggests

screening breast cancer patients for depressive symptoms and treating them. The research

also recommends social support treatments for breast cancer patients to promote mental

health. The study's findings affect academia and research. The report suggests studying

Saudi breast cancer patients' social support interventions. The report also suggests

studying Saudi breast cancer patients' depression symptoms.

The study suggests providing breast cancer patients with mental health and social

assistance. The study suggests that Saudi breast cancer patients receive culturally

acceptable treatment. The study found depression symptoms among Arab breast cancer

patients at King Abdullah Medical City, Makkah, Saudi Arabia. The study also found that

social support reduces depression symptoms in Arab breast cancer patients. The study

emphasizes mental health and social assistance for Saudi breast cancer patients. Overall,

35
it was found that Arab breast cancer patients at King Abdullah Medical City, Makkah,

Saudi Arabia, exhibit depressive symptoms. Social support also negatively correlated

with depression symptoms in Arab breast cancer patients. The study emphasizes the need

for mental health and social support for Saudi breast cancer patients in clinical, academic,

and research contexts. Future studies should examine the efficacy of social support

therapies for Saudi breast cancer patients and the variables that cause depressive

symptoms.

Interpretation of the Study Findings

Arab breast cancer patients at King Abdullah Medical City, Makkah, Saudi Arabia, had

significant rates of depression, according to the study. Saudi breast cancer sufferers

require mental health services. Social support also negatively correlated with depression

symptoms in Arab breast cancer patients. Social support measures may help Saudi breast

cancer patients with depression. These findings corroborate prior studies on breast cancer

patients' mental health and social support (Alananzeh et al., (2021). The study's

demographic, context, and validated measurements add to the literature. The study's

limitations—small sample size and self-reported measures—should be considered when

interpreting the results. The study's findings emphasize the need for mental health and

social care for Saudi breast cancer patients, which has therapeutic consequences. The

study's findings suggest that social support interventions for Saudi breast cancer patients

and the causes of depressive symptoms in Saudi breast cancer patients need further study.

36
Our study examined depressive symptoms and social support in Arab breast cancer

patients at King Abdullah Medical City, Makkah, Saudi Arabia. The study indicated that

Arab breast cancer patients in Saudi Arabia had high rates of depression and that social

support reduces depression. These findings corroborate studies on breast cancer patients'

mental health and social support. Kang et al. (2020) examined how the COVID-19

pandemic affected medical and nursing workers in Wuhan, China. Medical and nursing

workers reported high worry, despair, and stress levels due to the COVID-19 pandemic.

The research emphasizes mental health assistance for healthcare personnel amid public

health emergencies (Adam & Koranteng, 2020).

Depression and anxiety's effects on breast cancer recurrence and death were examined in

Wang et al.'s 2020 study. Depression and anxiety increase breast cancer recurrence and

death, the study revealed. The study emphasizes mental health treatment to enhance

breast cancer patients' prognoses. Our study agrees with Kang et al. (2020) that breast

cancer patients need mental health assistance. Kang et al. (2020) considered a number of

variables, including contact with infected individuals and the availability of

psychological support, were linked to rising rates of emotional distress. Although

personnel used just a small fraction of available mental healthcare services, those who

were struggling recognized these programs as crucial in helping them recover from

temporary mental health crises and feel better overall. These results highlight the need for

mental health treatments to help frontline workers during times of widespread crises. Our

study observed that social support reduces depression symptoms in Saudi Arab breast

cancer patients, and this supports a recent study on breast cancer patient's mental health

and social support (Ban et al., 2021; Hina, 2021).

37
We found that Saudi breast cancer patients need mental health support. The study

indicated that Saudi Arab breast cancer patients have significant rates of depression.

Previous study has indicated that breast cancer patients are at higher risk of depression

and anxiety (Alagizy et al., 2020; Wang et al., 2020). Alagizy et al. (2020) found that

Depressive symptoms were experienced by 68.6% of the population, anxiety symptoms

by 73.3%, and felt stress by 78.1%. The effects of advanced illness, surgery, marriage,

rural residence, illiteracy, and lack of adequate income on the prevalence of moderate to

severe stress, anxiety, and depression were not statistically significant. However, the

effect of occupation on the prevalence of moderate to severe anxiety was, with an average

prevalence of 100% for the unemployed compared to a prevalence of 0% among those

who were working (p = 0). Clinically diagnosed depression and anxiety, gender, age (less

than 60), and shorter follow-up period (less than five years) were all shown to be

associated with a worse outcome by Wang et al. (2020). The independent significance of

sadness and anxiety in our study to predict breast cancer recurrence and survival is

highlighted. Improved outcomes for people with breast cancer and mental health issues

should be a primary focus of future research (Al-Shammari & Khalil, 2020). Our study

recommended integrating mental health assistance into Saudi breast cancer care to

improve patient's quality of life and psychological well-being.

As found in our study, depression was more common among the unemployed (50%) as

compared to full-time employees (32.5%) and part-time employees (12.5%). Similar

results were obtained by Alagizy et al. (2020) that those without jobs (97.7%) and those

in rural regions (77.3%) had higher rates of depression, although the difference was not

statistically significant. All of the patients who were jobless or not working had anxiety,

38
which was a statistically significant difference from the patients who were employed, and

81% of the patients who lived in rural regions had anxiety, which was not statistically

significantly different from the patients who lived in urban areas (Alagizy et al., 2020).

However, our study did not take into account the urban and rural factors.

According to Wondimagegnehu et al. (2019), ten percent to twenty-five percent of cancer

patients also suffer from depression, a severe co-morbid illness. It reduces the survival

rate of breast cancer patients and causes significant functional disability.

Wondimagegnehu et al. (2019) examined the prevalence of depression and its link to

social support among Ethiopians with breast cancer in Addis Ababa. It was found that one

in four people with breast cancer were depressed. Low levels of emotional and social

support from loved ones are linked to depression. As a result, Ethiopia should make

depression screening and psychosocial support part of standard breast cancer treatment.

Our study affects Saudi healthcare practitioners and policymakers. Our study emphasizes

screening breast cancer patients for depression and providing mental health assistance.

The report recommends that Saudi Arabian officials emphasize mental health assistance

for breast cancer patients.

It can be said that our study sheds light on Arab breast cancer patients' depressive

symptoms and social support. The study emphasizes the necessity for mental health care

for Saudi breast cancer patients and the relevance of social support. The study advises

that Saudi Arabian healthcare practitioners and policymakers integrate mental health

assistance into breast cancer care to improve patients' quality of life and psychological

well-being (Aprilianto et al., 2021). Research is needed to determine the efficacy of

different mental health assistance for breast cancer patients in Saudi Arabia and identify

39
barriers to receiving treatment (Arnold et al., 2022). Our study helps us understand Saudi

breast cancer patients' mental health requirements and emphasizes the need to treat them

to improve patients' quality of life and psychological well-being.

This study sheds light on depressive symptoms and social support among Arab breast

cancer patients in Saudi Arabia. Like every research study, this one has limitations that

should be addressed when interpreting the results. In our case, sample size limits the

study. Only 98 Makkah-based breast cancer patients were studied. This sample may not

reflect all Saudi breast cancer patients, and the findings may not apply to other groups. A

bigger sample size would have boosted statistical power and generalizability. Small

sample sizes can affect several research topics. Concerns include low generalizability.

Applying results from a small sample to a larger population may be difficult (Alvi, 2016).

Small samples also raise the chance of sampling error, which is the difference between

the sample and the population. This reduces accuracy. Small samples weaken statistical

power. Statistical power detects true effects or correlations between variables. Small

samples diminish statistical power, making it difficult to identify actual effects and

raising type II errors. Small samples are also biased more. Outliers or unrepresentative

people can distort outcomes. To avoid biases, researchers should carefully draw

conclusions from small samples (Alvi, 2016).

Small samples restrict population variability analysis. These limits study depth and

understanding. Small samples reduce precision and dependability. Wider confidence

intervals and margin of error calculations reduce estimate precision. Precision increases

with sample size. Small samples might also make it hard to detect unusual occurrences.

Small samples may not be adequate to research unusual events (Alvi, 2016).

40
Confounding factors affect the connection between variables and are more likely in small

samples. Due to the small sample size, confounding factors may skew the results.

The cross-sectional design is one of the limitations of the study. The study's one-time data

collection reduces the causality between social support and depression symptoms.

Longitudinal studies of breast cancer patients might help explain how social support

affects depression symptoms over time. Self-reported social support and depressive

symptoms may have been biased in the study (Chen et al., 2020). Patients' under or over-

reporting symptoms and social support may affect the study's findings. Clinical

interviews or physiological measurements of social support and depression symptoms

might increase the validity of future investigations.

Its concentration on Saudi Arab breast cancer patients is another drawback. The study did

not include patients from other ethnicities or cultures; therefore, the results may not apply

to other groups. To examine social support and depressive symptoms across ethnicities

and cultures, future breast cancer research might involve a more varied sample. The study

did not examine the best social support for Saudi breast cancer patients. Emotional,

informational, and material social assistance may affect patients' mental health differently

(Civilotti et al., 2021). Future research might identify the best social support for Saudi

breast cancer patients and how to deliver it. The study also has practical constraints.

Convenience sampling may have caused selection bias in the study. The study's

conclusions may be less generalizable if participants were different from non-

participants. One data-gathering strategy may have restricted the study's data. Future

research might include questionnaires, interviews, and focus groups to better understand

breast cancer patients.

41
Despite these limitations, our study sheds light on Saudi breast cancer patients' mental

health issues. The study emphasizes the relevance of social support in enhancing patients'

quality of life and psychological wellness and the necessity for future research on breast

cancer patients in Saudi Arabia's mental health care options.

This study's findings demonstrated a link between having social support and a lower risk

of depression. Family support was observed to be adversely related to depression among

breast cancer patients in China and Ghana, while other research found that social support

was lower among depressed women with breast cancer (Liu et al., 2021; Kugbey et al.,

2020). The study's biggest shortcoming is that it is cross-sectional, so it's hard to say

which way the link runs between social support and depression. In addition, the study

only included individuals with breast cancer who went to healthcare institutions;

therefore, the results cannot be extrapolated to all breast cancer patients. The primary

strength of our study is the adoption of a reliable and valid instrument to assess

depressive symptoms in the study population. Future research can enhance breast cancer

care and support in Saudi Arabia and elsewhere by addressing these limitations and

expanding on the study's findings.

Chapter Six: Implications, Recommendations, and Conclusions

Implications

Our study affects clinical practice, academic research, and policymaking. The study

emphasizes mental health care for Saudi breast cancer patients. According to the study,

social support may improve patients' quality of life and mental health. Social support can

42
benefit patients, and healthcare practitioners should help them get it (Dewan et al., 2022).

Second, the study highlights the need for greater mental health studies on Saudi breast

cancer patients. The study suggests that Saudi breast cancer patients' depressed symptoms

are not well understood. Future studies might examine the best social support for patients

and the efficacy of various mental health therapies.

Important public health implications stem from our findings, which provide strong

support for the involvement of depression and anxiety in breast cancer development and

death. Breast cancer patients' emotional suffering must be recognized and addressed as a

first step. More health education is needed to make breast cancer patients and their

families aware of the relevance of psychological aspects, given the high incidence of

psychosocial distress and its negative consequences on cancer recurrence and death

(Fisher et al., 2021). Second, it is suggested that regular screenings and early detection be

implemented. Screening at regular intervals can successfully monitor psychological

changes in the early stage of cancer care, allowing for appropriate intervention to prevent

worsening sadness and anxiety (Gomez et al., 2019). Our findings also provide indirect

support for the need for mental health care for those with breast cancer. Finally, the study

affects policymaking. The findings imply that Saudi breast cancer patients need more

mental health treatments. Policymakers should guarantee that patients have access to

proper mental health support services and that healthcare practitioners are sufficiently

trained.

Recommendations

Several treatment and research suggestions can be offered. First, research should discover

the best social support for Saudi breast cancer patients. Emotional, informational, and

43
material support should be explored and customized to this population's

requirements. Second, healthcare workers need mental health training to help breast

cancer patients. This training should recognize and treat depression signs and teach social

assistance. Breast cancer patients can receive complete physical and psychological

treatment from healthcare practitioners with the right skills and understanding. Finally,

governments and legislators should prioritize mental health care for Saudi breast cancer

patients. Support and extend mental health services to make them accessible to all

patients (Hina, 2021). Breast cancer patients should also be required to undergo mental

health care as part of their treatment. Healthcare providers, researchers, and governments

may enhance Saudi breast cancer patient's quality of life and mental health by following

these guidelines. Recognizing and addressing these patients' mental health issues can

improve their treatment outcomes and the breast cancer community in Saudi Arabia.

Conclusions

The study at King Abdullah Medical City in Makkah, Saudi Arabia, illuminated Arab

breast cancer patients' depressive symptoms and social support. Saudi breast cancer

patients had a high prevalence of depression, underscoring the need for mental health

assistance. Social support was negatively correlated with depressive symptoms,

highlighting the need for social support for patients' mental health. The findings suggest

screening breast cancer patients for depression and incorporating mental health care into

treatment. Despite the study's modest sample size and cross-sectional methodology, the

findings add to the literature on breast cancer patients' mental health and social support.

Future research should include bigger and more varied populations, longitudinal designs,

and objective measures of social support and depressive symptoms.

44
The study recommends studying the best social support for Saudi breast cancer patients,

educating healthcare providers to recognize and treat mental health difficulties, and

providing proper mental health therapies. Saudi breast cancer sufferers may benefit from

these suggestions. The study emphasizes the need to treat breast cancer patients' mental

health issues, particularly in Saudi Arabia, and suggests therapeutic and research paths to

improve treatment and support for this population. Healthcare providers, governments,

and researchers may improve outcomes and patient well-being for Saudi breast cancer

patients by stressing mental health and social support. The study's conclusions affect

clinical practice, academic research, and policymaking. Research should continue to

identify the best social support for patients and evaluate mental health therapies.

45
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APPENDIX
Appendix No. 1

55
56
 Appendix No. 2

The Multidimensional Scale of Perceived Social

Support

57
58
 Appendix No. 3:

Consent Form

Dear Participants,

I'd like to invite you to take part in my study titled: THE ASSOCIATION
BETWEEN SOCIAL SUPPORT AND DEPRESSIVE SYMPTOMS IN
ARAB PATIENTS DIAGNOSED WITH BREAST CANCER

The study aims to be to determine the association between social support and
depression symptoms among Arab breast cancer patients in Makkah, Saudi
Arabia's King Abdullah Medical Cit. I do appreciate your time in
answering the questionnaire which will take from 10 to 15 minutes. For
any query about this project, please contact me.

IRB committee in KAMC reviewed and approved this study.

Please keep in mind that your involvement is entirely at your discretion, and all
of your personal information will be kept confidential and anonymously.

Primary investigator

Afnan Ali Mohammad Aljuraibi

59
 ‫نموذج الموافقة على المشاركة‬

‫أعزائي المشاركين‬

‫أود أن أدعوكم للمشاركة في دراستي بعنوان‪ :‬العالقة بين الدعم االجتماعي وأعراض االكتئاب في المرضى العرب‬
‫الذين تم تشخيص إصابتهم بسرطان الثدي‬

‫تهدف الدراسة إلى تحديد العالقة بين الدعم االجتماعي وأعراض االكتئاب لدى مرضى سرطان الثدي العرب في مكة‬
‫المكرمة ‪ ،‬مدينة الملك عبد هللا الطبية في المملكة العربية السعودية‪ .‬أنا أقدر وقتك في اإلجابة على االستبيان الذي‬
‫سيستغرق من ‪ 10‬إلى ‪ 15‬دقيقة‪ .‬ألي استفسار حول هذا المشروع ‪ ،‬يرجى االتصال بي‪.‬‬

‫قامت لجنة ‪ IRB‬في مدينة الملك عبدهللا الطبية بمراجعة واعتماد هذه الدراسة‪.‬‬

‫يرجى أن تضع في اعتبارك أن مشاركتك تتم وفقًا لتقديرك تما ًما ‪ ،‬وستظل جميع معلوماتك الشخصية سرية ومجهولة‬
‫الهوية‪.‬‬

‫أفنان علي محمد الجريبي‬

‫‪60‬‬