Body Image, Life Satisfaction and Associated Factors Among Women in Sweden having Undergone Mastectomy after Breast Cancer

Background: Women having undergone mastectomy due to breast cancer have experience which is very much individual and contextual. In order to facilitate efforts to understand the women and improve their quality of life, the aim of this study was to investigate body image, life satisfaction and associated factors among women having undergone mastectomy. Methods: Four hundred and eighty-one women in Sweden having undergone mastectomy after breast cancer were enrolled in a descriptive cross-sectional study. Each participant completed a questionnaire comprising socio-demographic characteristics, social support, body image and life satisfaction. Multiple linear regression analyses estimated relationships between socio-demographic characteristics, information support, social support, and treatment variables, and continuous outcome variables such as body image and life satisfaction). Results: Body image was associated with all dimensions of life satisfaction. Lower age, underlying disease, chemotherapy and breast reconstruction increased body image dissatisfaction, while treatment options were factors associated with life satisfaction. Total social support was a factor that increased life satisfaction in the dimensions of physical symptoms, sickness impact and quality of close friend relationship. Conclusion: The ndings highlight that some socio-demographic characteristics, treatment options and social support were associated with body image dissatisfaction and life dissatisfaction among the women with breast cancer after mastectomy. This can increase healthcare professionals’ understanding of women with breast cancer after treatment. They should provide effective information, focus attention on the women’s needs, and prepare intervention programs that make the women cope with their life situations during follow-up care.

mastectomy. By understanding factors associated with body image and life satisfaction in Swedish women after mastectomy, health care professionals can coordinate interventions to improve quality of life among these women and provide speci c and meaningful support in accord with their needs. Therefore, the aim of this study was to investigate body image, life satisfaction and associated factors among women in Sweden after mastectomy.

Study setting and design
A descriptive cross-sectional study using quantitative method was conducted. Data were collected in three Swedish cities: Falun, Gävle and Uppsala.

Participants
Women with breast cancer were selected by use of the registration of the Regional Cancer Centres (RCCs) in Uppsala and Örebro. The criteria for selection were: women (1) having breast cancer diagnosis since at least one year and having undergone mastectomy, (2) of age at least 18 years, (3) living in Falun, Gävle or Uppsala, (4) with or without breast reconstruction, and (5) willing to participate in the study. In total 481, out of 975 eligible women accepted to participate by returning a questionnaire.

Instruments
The questionnaire comprised four parts devoted to (1) socio-demographic characteristics, (2) social support, (3) body image, and (4) life satisfaction. The rst two parts, developed by the authors for this study, are provided as Supplementary File 1.
The socio-demographic characteristics part concerned age, civil status, educational level, religion, cultural/ethnic minority, underlying disease (chronic), duration of diagnosed breast cancer, types of treatment (mastectomy, chemotherapy, radiation therapy, Herceptin (HER-2), and hormone therapy), and breast reconstruction.
The social support part concerned information support from physicians, nurses, internet, partner, family and friends, and other sources. This part had 54 questions, nine for each source. Each question provided a score of zero or one. Therefore, the score ranged from zero to nine for each source of information, and the total score for social support ranged from zero to 54, where a higher score indicates a more total social support. This part had Cronbach's alpha = 0.89. Body image was evaluated by using the Body Image Scale (BIS) [22], a ten-item scale with four possible responses: 0 (not at all), 1 (a little), 2 (quite a bit), and 3 (very much). The range of possible scores was from zero to thirty, where a higher score indicates more dissatisfaction with body image. This scale was translated to Swedish and tested for validity by experts. It had been tested for reliability by the authors on breast cancer patients who did not participate in this study with Cronbach's alpha = 0.93. Life satisfaction was measured by using a life satisfaction questionnaire (LSQ) [23]. It was constructed to measure life satisfaction/quality of life in women with breast cancer. It had 34 items with six dimensions: physical symptoms, sickness impact, quality of everyday activities, socio-economic situation, quality of family relation, and quality of close-friend relationship. Each item had a 7-point scale, ranging from 1 to 7. An example of an item is "How much have you been troubled by tiredness during the last week?" Its scale is: 1 to a very high degree, 2 to a high degree, 3 to a fairly high degree, 4 to some degree, 5 to a low degree, 6 almost not at all, and 7 not at all. The last alternative represents the highest quality in all terms. The raw scores of the items are added, divided by the highest point in that scale and multiplied by 100. This makes it possible to compare the different factors although there are unequal numbers of items in the dimensions. Thus, 100 represents the maximum quality of life in each dimension. A higher score implied a better life satisfaction. This scale had been tested for reliability by the authors on breast cancer patients who did not participate in this study with a Cronbach's alpha ≥ 0.70 for each dimension.

Procedure
After the heads of the clinics of surgery/oncology and plastic surgery in Falun, Gävle and Uppsala had been informed about the research project, they gave permission to conduct it. Also the nurses of the clinics were informed about the study in order to be able to answer questions from the participants.
Written information about the study and its purpose, a consent letter and a questionnaire were sent to the selected women by post. They were assured anonymity and con dentiality and were told that they could drop out at any time. The ethical requirements of the Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects were ful lled. Each questionnaire had a code number to facilitate reminders. The women who were interested to participate signed the consent letter, answered the questionnaire and returned these documents in a pre-stamped envelope while those who did not want to participate returned the consent letter and the questionnaire without lling them in. A maximum of two postal reminders were sent after two weeks and one month if the women did not return the envelopes.
We created hypothetical Directed Acyclic Graphs (DAGs) based on reviewed literature [24][25][26] with the aim to demonstrate what possible factors are associated with body image (Fig. 1a) and with life satisfaction (Fig. 1b).

Statistical analysis
We analyzed data using descriptive and inferential statistics. Descriptive statistics summarized sociodemographic characteristics of participants, such as frequency and mean. Inferential statistics applied correlation and linear regression analyses. The level of statistical signi cance for all analyses was set at p = 0.05. Pearson's correlation was performed to determine the differences between BIS scores and LSQ scores from six dimensions.
Multiple linear regression analyzes estimated relationships between socio-demographic characteristics, each kind of information support, total social support, and treatment variables and outcome variables (i.e. body image and life satisfaction). The outcome variables were continuous variables, where the BIS score represented the body image and the LSQ score represented the life satisfaction. The LSQ score had seven dimensions: physical symptoms, sickness impact, quality of everyday activities, socio-economic situation, family relation, close-friend relationship, and overall life satisfaction. Therefore, there were eight outcome variables. Assumptions were satis ed before the analyses (i.e. auto-correlation, multicollinearity, homoscedasticity, linearity, and multivariate normality). Socio-demographic variables included age, duration from diagnosis, having an underlying disease, culture/ethnic minority, civil status, and education level, and treatment variables included chemotherapy, radiation therapy, hormone therapy, Herceptin, and breast reconstruction. Age, duration from diagnosis, and each information support and total social support were continuous variables. Dummy variables (categorization to zero and one) were having an underlying disease, culture/ethnic minority (no = 0, yes = 1), civil status (married/lived together = 0, the others = 1), education level (high school or above = 0, secondary school/others = 1), and the treatment variables (no = 0, yes = 1). First, we inserted each socio-demographic characteristic, each information support, total social support and treatment variable into simple linear regression for each outcome variable. Signi cant socio-demographic characteristic, information support and total social support and treatment variables from the simple regression retained in the multiple stepwise linear regression analyses. We adjusted the civil status and education level as confounders in the multiple regression for all outcome variables. We provided adjusted R 2 and a standardized partial regression coe cient (β) and 95% con dence interval (CI) to demonstrate the tness and strength of association of each outcome variable.

Results
Many of the participants were 61-75 years old (41.6%), and about half of them were married (49.3%). About 90% of them were Christians, and 60% of them had an underlying disease. See Table 1.   Table 2.  independently associated with increased total life satisfaction. See Table 3.

Discussion
This study revealed that the body image after mastectomy of the participating women correlated with all dimensions of life satisfaction. It seems that mastectomy in uenced the physical, psychological and social aspects of the women and it negatively affected the women's body image. They had to deal with the trauma of dis gurement and with fear of loss of femininity. Some studies showed that body image was associated with quality of life in women with breast cancer [6,[8][9][10], and the type of surgery had impact on the appearance satisfaction [8,27]. The participating women's body image was associated with life satisfaction in the dimensions of sickness impact and quality of everyday activities. The reason may be that after mastectomy the women felt dissatisfaction with their appearance and with surgical scars. The body image depends on the states of health and physical functioning [9,28], and negative body image may reduce patients' ability to cope with breast cancer after surgery [12,13]. This study highlights that the body is a key aspect of the women's life satisfaction after mastectomy. Therefore, healthcare professionals should be aware of the changes experienced by the women after mastectomy and provide speci c information, psychosocial support and follow-up care. In addition, it is necessary to determine which intervention would minimize negative body-related self-perceptions, cognition, emotions and behaviors, and enhance women's physical and psychosocial health and well-being.
Lower age, underlying disease, chemotherapy and breast reconstruction increased the body image dissatisfaction among the participating women after mastectomy. The body image of young women after loss of a breast with resulting scars and physical changes [29] due to mastectomy may have an impact on the overall quality of life and their partner relationships [8]. Age and type of treatment had the greatest impact on younger women [14] who had worse body image after treatment than elder women [30,31]. Additionally, chemotherapy results in physical symptoms such as hair loss, weight gain and menopausal symptoms that distress young women [32,33]. One option after mastectomy is to undergo a breast reconstruction. Women choose this option because they want to get rid of the external prosthesis, feel whole again, regain femininity, and have fewer clothing limitations [16]. However, younger women with mastectomy and reconstruction as treatment for breast cancer report negative body image [34,35].
Therefore, healthcare professionals should understand factors that may lead to physical and psychological distress of women after mastectomy.
The study re ects factors such as total social support and treatment options that are associated with life satisfaction among women having undergone mastectomy. Total social support increased life satisfaction in the dimensions of physical symptoms, sickness impact, and quality of close-friend relationship. This may explain that the women went through the treatment leading to different physical symptoms and distress that affected their daily activities and role functioning. The women needed support from their friends to cope with their life situations. Social support is a main factor for life satisfaction related to physical and psychological aspects of the women after mastectomy. Lack of social support was associated with poorer health related to long-term quality of life [36]. Support from family and friends was characterized by reassurance, comfort, and help with problem-solving during the period after diagnosis [37]. Effective support comes from family, friends, colleagues, or healthcare professionals [38,39]. The results of this study may enhance healthcare professionals' awareness of the highly individual needs of support by the women who may be encouraged to express what they actually want regarding social support from their social networks. In this way psychosocial support can be offered to the women so that they can cope with physical changes emotional distress and pursue their daily activities.
Change in appearance after mastectomy is a traumatizing and distressing experience that affects the women's daily lives, social activities, relationships, and quality of life [29]. Treatment options, e.g.
chemotherapy and radiation therapy, were factors in uencing life satisfaction in the dimensions of physical symptoms and sickness impact. They may explain that the women experienced side effects of the treatments associated with physical symptoms. Women having side effects are often confronted with a range of challenges in their daily activities such as work, nutrition, sleep and social activities [40]. It is evident from the results of this study that healthcare professionals can increase their understanding of women during and after treatment and of which factors may affect the women's body image and life satisfaction. DAGs for body image dissatisfaction and life satisfaction from reviewed literature demonstrated what confounding factors could be expected and assisted the data analysis. Multiple linear regression presented strengths of association and adjusted confounders. Data analyses using real scores from questionnaires maximized estimates of ndings [41]. In addition, all instruments used in this study had been tested with good validity and reliability scores.

Strengths and limitations
The cross-sectional study limited a cause-effect relationship. Therefore, a longitudinal study might better explain factors associated with body image dissatisfaction and life satisfaction. Also, this study relied on self-report, which could give rise to information biases. Although the number of participants was high (n = 481), the response rate was only about 50%. This could affect sub-group analyses, e.g. with respect to religion.

Conclusion
This study revealed that the body image of women after mastectomy correlated with all dimensions of life satisfaction. Low age, underlying disease, chemotherapy and breast reconstruction increased body image dissatisfaction. Treatment options were factors associated with life satisfaction in the dimensions of physical symptoms and sickness impact. Additionally, total social support was a factor that increased life satisfaction with respect to physical symptoms, sickness impact and quality of close-friend relation. This study highlights that women with breast cancer having factors associated with body image dissatisfaction and life dissatisfaction were population-at-risk for physical and mental health impact.
Therefore, the results of this study can give healthcare professionals increased understanding of women after mastectomy and of what factors are associated with their body image and life satisfaction.
Healthcare professionals should provide effective information and support focusing on the women's own needs. In addition, healthcare professionals should prepare and develop an intervention program with aim to help women cope with their life situations after mastectomy and during follow-up care.

Declarations
Ethics approval and consent to participate