Social isolation in adults with cancer: An evolutionary concept analysis — TEI-tagged view

Yanjing LiangpersName, Guihua HaopersName, Mei WupersName, Lili HoupersName (2022date). “Social isolation in adults with cancer: An evolutionary concept analysis.” Frontiers in Psychologytitle·j.

Object of study — social isolationterm·dom among adults with cancerterm·key

Research question — what social isolationterm·dom means in adults with cancerterm·key, and what its antecedentsterm·mth, attributes and consequencesterm·mth are

Contribution — a conceptual definition of social isolationterm·dom in adults with cancerterm·key, with six antecedentsterm·mth, two attributes and three consequencesterm·mth

Full text — tagged

Social isolationterm·dom in adults with cancerterm·key: An evolutionary concept analysisterm·key Abstract In extant literature, the concept of social isolationterm·dom has been explored primarily in the context of older adults. However, people with cancerterm·key may also experience social isolationterm·dom, and there is a need for increased clarity regarding this phenomenon in this population.

To conceptualize social isolationterm·dom in adult cancerterm·key care.

PubMed, Web of Science, PsycINFO, CINAHL, China National Knowledge Infrastructure, Wanfang Data, and the Chinese Biomedical Literature Database were systematically searched using the key terms “cancerterm·key,” “social isolationterm·dom,” “social alienationterm·dom,” and “social exclusionterm·dom” for studies (from the earliest date available to June 2022). The main disciplines involved were psychology, nursing, medicine, and public health. Rodgers’ evolutionary concept analysisterm·key was employed to clarify the antecedentsterm·mth, attributes, and consequencesterm·mth of social isolationterm·dom in adults with cancerterm·key.

A total of 60 eligible articles were reviewed entirely and the main findings were categorized into antecedentsterm·mth, attributes, and consequencesterm·mth. The antecedentsterm·mth of social isolationterm·dom were classified into six categories: cancer-related physiological changes, cognitive beliefsterm·dom, psychological wellbeing, unsatisfactory social supports or relationships, restrictions associated with receiving treatments, and social-level barriers. Attributes were characterized according to behavior or social avoidanceterm·key and negative affective experiences, while consequencesterm·mth were attributed to low therapeutic compliance, poor health conditions and mental health problems, and low quality of lifeterm·dom. White’s heuristic model is a potential theoretical context applicable to social isolationterm·dom in adults with cancerterm·key.

This concept analysisterm·key provides a basis for developing multidimensional assessment tools and measures to alleviate social isolationterm·dom in adults with cancerterm·key, a complex and varied phenomenon. However, while this review contributes to the current knowledge on social isolationterm·dom in people with cancerterm·key, studies should further investigate the relationships among attributes associated with social isolationterm·dom.

Keywords: social isolationterm·dom, cancerterm·key, psychological nursing, psychosocial behavior, concept analysisterm·key Introduction Globally, over 19 million individuals are diagnosed with cancerterm·key annually ( Sung et al., 2021 ). Cancerterm·key diagnosis and treatment can cause severe adversity, resulting in varying psychological distress levels ( Sender et al., 2020 ). However, with advances in healthcare, survival rates are also higher, and there is now increased advocacy to enhance the quality of survivorship care. Consequently, treatment goals include improving patients’ quality of lifeterm·dom, symptom management, and psychosocial effects ( Bray et al., 2018 ; Nekhlyudov et al., 2019 ). Despite this, limited attention has been paid to severe psychosocial issues, among which social isolationterm·dom is one.

The term “social isolationterm·dom” was introduced in Berkman and Syme’s (1979) seminal study. Initially, it referred to individuals who lacked social networks or had limited social supports. Thereafter, it was developed concurrently across multiple disciplines including public health, medicine, and nursing ( Nicholson, 2009 ). In public health literature, the definition of social isolationterm·dom evolved from “…irreversible loss of social bonds” ( Berkman, 1983 ) to “lack of attachments within a person’s social network” ( LaVeist et al., 1997 ). In the context of nursing, the subjective feeling of the unmet needs for social connections or supports and experiences of lonelinessterm·dom have been emphasized ( Lien-Gieschen, 1993 ; Biordi, 1998 ; Ackley and Ladwig, 2004 ), while medicine views it as an objective indicator of social contact ( Havens et al., 2004 ). The final definition of this concept incorporates both subjective and objective measures. Specifically, social isolationterm·dom is characterized by minimal contact with other people and limited involvement in community affairs ( Iredell et al., 2004 ).

The aforementioned definitions of social isolationterm·dom have generally been developed with reference to older adults. Thus, an oncology-specific multidimensional definition of social isolationterm·dom is yet to be clarified. The experience of social isolationterm·dom and its associated attributes may differ among various age groups and by health conditions. Furthermore, social isolationterm·dom is a phenomenon associated with severe health consequencesterm·mth and has been expanded to cancerterm·key. Specifically, in the context of oncology, social isolationterm·dom has been analyzed primarily in patients with breast, prostate, head and neck, and lung cancersterm·key ( Ettridge et al., 2018 ; Ashi et al., 2020 ; Dornan et al., 2021 ; Kudjawu and Agyeman-Yeboah, 2021 ).

Several studies underscore the impact of social isolationterm·dom. Research indicates that social isolationterm·dom is linked with the increased risk of tumor recurrence and mortality among patients with breast cancerterm·key ( Kroenke et al., 2017 ). Friedler et al. (2015) summarized several studies on the pathophysiological mechanisms of social isolationterm·dom, revealing that it affects the immune system, autonomic nervous system, and neuroendocrine axis. Moreover, long-term social isolationterm·dom may increase the risk of mental illness ( Yuan et al., 2020 ), reduce patient compliance with treatment, and increase cancerterm·key care costs ( de Souza et al., 2017 ). Despite a lack of in-depth explorations, there is increasing evidence to suggest that social isolationterm·dom could impact health in adults with cancerterm·key. This may be attributed to the different implications of social isolationterm·dom between adults with cancerterm·key and older adults. The concept of social isolationterm·dom in adults with cancerterm·key remains unclear. Therefore, this study aimed to clarify the meaning of social isolationterm·dom in adults with cancerterm·key and examine its antecedentsterm·mth, attributes, and consequencesterm·mth by conducting a concept analysisterm·key.

Materials and methods Identifying a concept Rodgers’ concept analysisterm·key method is an inductive process ( Rodgers, 2000 ). In Rodgers’ view, concepts evolve and are shaped by the context in which they are used. Therefore, they are constantly developed and redefined. There have been studies on social isolationterm·dom across various fields. Furthermore, the meaning of the associated terms has been established over the years. Thus, we applied Rodgers’ evolutionary concept analysisterm·key method and reviewed the literature on social isolationterm·dom focusing on people with cancerterm·key to understand social isolationterm·dom in the cancerterm·key context ( Table 1 ; Rodgers, 2000 ).

Steps for Rodgers’ evolutionary concept analysisterm·key.

Sources of data We conducted systematic electronic searches (from the earliest date available to June 2022) of PubMed, Web of Science, PsycINFO, CINAHL, China National Knowledge Infrastructure, Wanfang Data, and the Chinese Biomedical Literature Database using combinations of the terms “cancerterm·key,” “social isolationterm·dom,” “social alienationterm·dom,” and “social exclusionterm·dom” in the abstract or title. The inclusion criteria were articles that were published in English or Chinese; had undergone peer review (excluding dissertations, theses, or comments); and underscored social isolationterm·dom in people with cancerterm·key, specifically concepts, antecedentsterm·mth, attributes, and consequencesterm·mth. Searches were conducted without any time and discipline constraints to ensure the identification of as many relevant articles as possible and to provide an overview of the concept’s use over time. The exclusion criteria were published abstracts of studies that did not contain specific information on social isolationterm·dom and studies conducted on non-cancer populations.

The original search resulted in 711 articles after deleting duplicates using the NoteExpress 3.5.0.9054 software ( Figure 1 ). Upon performing further screening based on the exclusion criteria by reading the titles and abstracts of the articles, a sample size of 312 was obtained. There was no consensus on the criteria for evaluation of the data sources included in the concept analysisterm·key; only articles that mentioned social isolationterm·dom in people with cancerterm·key were included. Duplicate studies that were not recognized by the software were manually deleted. Studies with insufficient information regarding the characteristics of social isolationterm·dom in people with cancerterm·key, making attribute identification difficult, were also removed. This resulted in the removal of 252 of the 312 studies. Rodgers (2000) recommends that the total number of references per discipline included in a study should be approximately 20% of the total. This was not feasible in the current study. To gain a deeper insight into social isolationterm·dom, the remaining 60 selected studies were included in this concept analysisterm·key. Finally, the disciplines involved were psychology ( n = 12), nursing ( n = 24), medicine ( n = 19), public health ( n = 3), medical informatics ( n = 1), and epidemiology ( n = 1).

Flow chart of the study screening process. The studies obtained from each database are as follows: PubMed ( n = 16), Web of Science ( n = 5), PsycINFO ( n = 22), CINAHL ( n = 12), China National Knowledge Infrastructure ( n = 3), Wanfang Data ( n = 2), and the Chinese Biomedical Literature Database ( n = 0).

Data collection and management Based on Rodgers’ method, the articles were studied for the identification of surrogate terms and related concepts. Furthermore, they were reviewed for systematic data collection and management in terms of attributes, antecedentsterm·mth, and consequencesterm·mth of the concept. The aforementioned information was extracted and tabulated. Among the 60 articles reviewed, an explicit definition of social isolationterm·dom was rare. Thus, not all articles were extracted for their attributes of the concept. The data sources were reviewed by two of the researchers and checked by a third ( Zhu et al., 2018 ). The matrix was developed by YL and MW.

Data analysis The included articles were coded according to antecedentsterm·mth, attributes, consequencesterm·mth, surrogate terms, contextual basis, and theoretical and practical definitions. The coding was conducted using the standard procedure of thematic analysis underscored in Rodgers’ evolutionary method ( Rodgers, 2000 ). Independently, two reviewers partially completed the work before discussing it with a third to reach a cohesive and comprehensive consensus to minimize bias as much as possible. Finally, the review team developed the conceptual definition of social isolationterm·dom in people with cancerterm·key ( Zhu et al., 2018 ).

Results Study characteristics The studies included in this analysis were published between 1980 and 2022; 55 were in English and five were in Chinese. Most employed cross-sectional and qualitative research designs. Patients with various types of cancerterm·key such as those affecting the lung, breast, head and neck, and prostate were included. The sample sizes ranged from three to 25,382. Only some studies included all the definitions, antecedentsterm·mth, attributes, and consequencesterm·mth of social isolationterm·dom.

Surrogate terms and related concepts Multiple terms have been used interchangeably with social isolationterm·dom. For example, social alienationterm·dom has been used in place of social isolationterm·dom ( Yang et al., 2021 ). While the term “social exclusionterm·dom” is distinct from “social isolationterm·dom,” it has been used to describe social isolationterm·dom in some studies ( Dahill et al., 2020 ). There are two main concepts—alienationterm·dom and lonelinessterm·dom—that need to be differentiated from social isolationterm·dom. According to Seeman (1959) , alienationterm·dom encompasses powerlessness, isolationterm·dom, normlessness, self-estrangement, and meaninglessness. Thus, isolationterm·dom is only one psychological state of alienationterm·dom. Some researchers use “lonelinessterm·dom” to express “social isolationterm·dom.” However, we did not use “lonelinessterm·dom” as a surrogate term in our search; using “social isolationterm·dom” and “lonelinessterm·dom” interchangeably can be confusing, as we found lonelinessterm·dom to be an attribute of social isolationterm·dom ( Raque-Bogdan, 2019 ; Raque-Bogdan et al., 2019 ).

Social isolationterm·dom definitions used in different cancerterm·key populations Definitions of social isolationterm·dom in adults with cancerterm·key have been presented in several studies with varying emphasis. Reduced social networks and lonelinessterm·dom are the most prevalent aspects of these definitions. Changing social health contexts, as influenced by factors such as coronavirus disease 2019 (COVID-19), have led to a spate of studies related to social isolationterm·dom ( Table 2 ).

Samples of social isolationterm·dom definitions applied in studies included in the analysis.

Attributes A concept is defined by distinct meanings, referred to as attributes. Attributes comprise a set of characteristics that can be used to categorize similar situations related to a certain concept ( Rodgers, 2000 ). During the analysis, two attributes underscored by succinct generalizations of social isolationterm·dom in people with cancerterm·key emerged. These attributes recurred in the description of social isolationterm·dom in data sources, and included behaviors and states of social avoidanceterm·key as well as negative affective experiences. Studies supporting each attribute are shown in Table 3 . Notably, there is a significant difference between external social isolationterm·dom and perceived or internal social isolationterm·dom. However, some patients experiencing the former (i.e., behaviors and states of social isolationterm·dom) may not experience negative affective experiences. It is imprudent to classify all the behaviors and states of social avoidanceterm·key simply as social isolationterm·dom and ignore emotional isolationterm·dom.

Overview of the characteristics and attributes of social isolationterm·dom defined in the studies included in the concept analysisterm·key.

Behaviors and states of social avoidanceterm·key States of social avoidanceterm·key States of social avoidanceterm·key include limitations regarding social networks, which are determined by the frequency of social contact, activity, communication, size, and diversity ( Liu B et al., 2021 ; Liu Y et al., 2021 ; Takemura et al., 2021 ). Discontinuing work after cancerterm·key diagnosis or treatment and relinquishing social roles are common for patients, and exacerbate feelings of isolationterm·dom ( De Blasi et al., 2018 ). To some extent, the choices of discontinuing work or relinquishing social roles belong to the social avoidance behaviorterm·dom attribute.

Social avoidance behaviorsterm·dom Some cancerterm·key survivors choose to self-isolate ( Ettridge et al., 2018 ; He et al., 2021 ). They are often reluctant to communicate with others, specifically concerning details of their illness. Social avoidance behaviorsterm·dom are more common among patients with prostate and rectal cancerterm·key ( Ettridge et al., 2018 ; Zhu et al., 2019 ; He et al., 2021 ). Social isolationterm·dom can be a passive choice induced by the inability to socialize like before due to medical conditions, surgery, and treatment effects. Notably, some cancerterm·key survivors conceal their identities and emotions (including hiding cancer-related information and feelings of lonelinessterm·dom) to protect themselves or their loved ones. This paradoxical behavior, aiming to eliminate negative emotions such as lonelinessterm·dom while hiding critical health-related facts from medical staff, patients, and their loved ones, requires increased prioritization ( Raque-Bogdan, 2019 ).

Negative affective experiences Lonelinessterm·dom has been reported as a negative effect among patients for several reasons. Cancerterm·key survivors experience distress, as they cannot speak about their illness with anyone except their intimate partners and medical specialists ( Ettridge et al., 2018 ; Zhu et al., 2019 ).

Furthermore, low self-esteem, generally linked to self-discrimination, has been identified as a negative affective experience. Some patients may experience negative self-perception or self-denial due to cancer-related physiological changes, and thus avoid contact with people around them ( Blinderman and Cherny, 2005 ; Ettridge et al., 2018 ). Behaviors and states of social avoidanceterm·key and negative affective experiences are closely related. Another manifestation of low self-esteem is the fearterm·dom of being humiliated in front of others ( Johansson et al., 2005 ).

Feelings of social exclusionterm·dom are common negative experiences resulting from the incapability to perform family or work roles owing to illness and result in survivors feeling excluded from society ( Rhoten et al., 2013 ; Simonelli and Otto, 2017 ; De Blasi et al., 2018 ; Puigpinós-Riera et al., 2018 ). For some women and young adults, the feeling of being in a life stage that is not consistent with peers is also an attribute of social isolationterm·dom ( Parton et al., 2017 ; De Blasi et al., 2018 ; Iannarino, 2018 ).

Antecedentsterm·mth Antecedentsterm·mth are events or phenomena that precede the concept ( Rodgers, 2000 ). Six antecedentsterm·mth of social isolationterm·dom were identified in adults with cancerterm·key. These included cancer-related physiological changes, cognitive beliefsterm·dom, psychological wellbeing, unsatisfactory social supports or relationships, restrictions on receiving treatments, and social-level barriers.

Cancer-related physiological changes Physiological change is the most common antecedentterm·mth of social isolationterm·dom among cancerterm·key survivors. Cancerterm·key survivors may experience physical and functional impairments caused by their illness and treatment, thus resulting in limited social integration ( Noyes et al., 1990 ; Sandén and Hydén, 2002 ; Johansson et al., 2005 ; Lund-Nielsen et al., 2005 ; Bennett et al., 2006 ; Simonelli and Otto, 2017 ; De Blasi et al., 2018 ; Abdollahimohammad et al., 2019 ; Borgi et al., 2020 ; Stolley et al., 2020 ; Yuan et al., 2020 ; He et al., 2021 ; Kudjawu and Agyeman-Yeboah, 2021 ; Tsui and Huang, 2021 ). For instance, the complications associated with head and neck cancerterm·key, such as disfigurement, dysphagia, and speech impairment, can impair social functioning among survivors, exacerbating social isolationterm·dom ( Rogers et al., 2016 ; Moore et al., 2018 ; Kirtane et al., 2022 ). For gastrointestinal cancerterm·key survivors, gastrointestinal-specific morbidities such as ostomy leakage and incontinence deter them from an active social life ( Martopullo et al., 2020 ; He et al., 2021 ). Other cancersterm·key (e.g., prostate, breast, and gynecological cancerterm·key) can impact survivors’ sexual life, as they may consider it an embarrassing topic to raise with friends and partners. These individuals need support, such as from peer groups, to express their challenges and share experiences ( Sandén and Hydén, 2002 ; Power and Hegarty, 2010 ; Campo et al., 2017 ; Ettridge et al., 2018 ; Iannarino, 2018 ). Thus, as their physical health deteriorates, cancerterm·key survivors become weaker, more dependent, and socially isolated, resulting in their inability to socialize as well as maintain and form relationships ( Schapmire et al., 2012 ; Carduff et al., 2018 ).

Cognitive beliefsterm·dom Cognitive beliefsterm·dom are also an important antecedentterm·mth of social isolationterm·dom. These refer to a set of habitual pattern recognitions that one is used to, which is “fundamental to a person’s world view” ( Charles et al., 2006 ). According to White’s heuristic cognitive behavioral model ( White, 2000 ), false beliefs may lead to negative behavior (e.g., social avoidanceterm·key). Regarding patients with rectal cancerterm·key tolerating stomas, two extreme attitudes can arise and prevent them from engaging in social activities. Stomas are sometimes treated inappropriately by patients who think their stomas are infectious and should quarantine themselves, while other times patients overprotect them, believing that they are fragile and thus should not be exposed ( He et al., 2021 ). Recently, cognitive and psychological influencing factors such as body image, which can lead to social avoidanceterm·key in people with head and neck cancerterm·key, have become research hotspots in the tumor population ( Rhoten et al., 2013 ). While the underlying mechanism of social isolationterm·dom in people with cancerterm·key is unclear, several theories can improve the understanding of the process that leads to it. The fear-avoidance model ( Newell, 1999 ) explains cancer-related changes from a cognitive-behavioral perspective. Social avoidance behaviorterm·dom among cancerterm·key survivors is caused by the fearterm·dom of changing appearances and functions. Fearterm·dom and avoidance are conditioned reflexes maintained by learned thinking that constantly reminds individuals of their flaws. Individuals who are unable to adapt to physical deficiencies often continue to avoid society. Regarding nursing practice, social isolationterm·dom can be guided by assessing the potential factors through understanding the avoidance behaviors demonstrated by patients based on this model.

Psychological wellbeing Psychological wellbeing is integral to holistic health. Psychological discomfort serves as an antecedentterm·mth of social isolationterm·dom in people with cancerterm·key. It has been suggested that social isolationterm·dom correlates positively with symptoms of anxiety and depression in patients with breast cancerterm·key ( Liu B et al., 2021 ; Liu Y et al., 2021 ). Studies have shown that people with cancerterm·key with impaired psychological status demonstrate higher social isolationterm·dom levels ( Im and Chee, 2021 ). Furthermore, anxiety and depressive symptoms have been identified as common predictors in patients with oral cancerterm·key who exhibit increased social isolationterm·dom levels due to stigma ( Yuan et al., 2020 ). A qualitative study conducted in Ireland found that cancerterm·key survivors experience persistent symptoms of fatigue, anxiety, depression, and pain after receiving treatment, which increases their social isolationterm·dom and reduces their activity levels. Notably, the first year after treatment involves managing the transition to survivorship and returning to daily life; survivors often feel isolated during this time ( Boland et al., 2019 ).

Unsatisfactory social supports or relationships Unsatisfactory social support is also an important antecedentterm·mth of social isolationterm·dom among cancerterm·key survivors. First, it may arise from not having someone with whom to discuss cancer-related matters ( D’Agostino and Edelstein, 2013 ; Ettridge et al., 2018 ; Zhu et al., 2019 ). According to cancerterm·key survivors, their lonelinessterm·dom results from external avoidance and misunderstandings from others and cancerterm·key’s long-lasting impact ( Fu et al., 2013 ; Hinzey et al., 2016 ; Raque-Bogdan et al., 2019 ; Kirtane et al., 2022 ). Second, the need for special attention for individuals with several intersecting identities might be unnoticed. It has been underscored that having several intersecting identities (e.g., lesbianism) may perpetuate a sense of isolationterm·dom among individuals after a cancerterm·key diagnosis owing to previous experiences with societal oppression or marginalization. Thus, it is imperative to analyze individuals’ underlying identities and life experiences before the illness to provide tailored social supports ( Raque-Bogdan, 2019 ). Moreover, individuals who live alone and do not have family or friends nearby may be more likely to experience social isolationterm·dom ( Fu et al., 2013 ; Ettridge et al., 2018 ; Leung et al., 2021 ). Some cancerterm·key survivors have reported that support from physicians and family members declines upon receiving treatment. This often leaves them feeling powerless and isolated because they still require care and support ( Power and Hegarty, 2010 ; Kirtane et al., 2022 ).

Restrictions associated with receiving treatments Patients with neutropenic cancerterm·key are sometimes placed in protective isolationterm·dom at the hospital, enhancing their sense of security during treatment. Patients often practice self-isolation by refusing to interact with people, both emotionally and physically, to protect both themselves and others. Specifically, these patients often feel powerless ( Lee et al., 2011 ). Similarly, several patients with head and neck cancerterm·key required isolationterm·dom for radiochemotherapy during the COVID-19 pandemic, which exacerbated social isolationterm·dom ( Kirtane et al., 2022 ).

Social-level barriers Research has indicated that the public health events associated with COVID-19 social distancing measures imposed more lonelinessterm·dom and social isolationterm·dom, which are both stress-inducing factors ( Miaskowski et al., 2020 ; Kirtane et al., 2022 ). Several lung cancerterm·key survivors reported that they were excluded from social activities. Consequently, experiences of exclusion increased their reluctance to engage with society ( Liu et al., 2016 ). In Syria, cancerterm·key is not sufficiently understood and accepted by the public, and people with cancerterm·key often fearterm·dom that chemotherapy will prevent them from marrying owing to effects that may impact their social functioning ( Nizamli et al., 2011 ).

Consequencesterm·mth Consequencesterm·mth refer to the results of corresponding events or phenomena ( Rodgers, 2000 ). The literature suggests that social isolationterm·dom is generally accompanied by three consequencesterm·mth, namely, low therapeutic compliance, poor health conditions and mental health status, and low quality of lifeterm·dom.

The first consequenceterm·mth of social isolationterm·dom is low therapeutic compliance. Healthcare professionals often emphasize treatment compliance to patients. However, perceived social isolationterm·dom among patients with cancerterm·key negatively impacts their treatment compliance ( de Souza et al., 2017 ; Iannarino, 2018 ; Martopullo et al., 2020 ; Stolley et al., 2020 ). The second consequenceterm·mth is poor health conditions and mental health status. A systematic review has indicated that social isolationterm·dom and lonelinessterm·dom can increase mortality rates, regardless of their link to underlying medical conditions ( Kroenke et al., 2013 ; Holt-Lunstad et al., 2015 ; Zhu et al., 2019 ). Furthermore, a high symptom burden is associated with lonelinessterm·dom and social isolationterm·dom ( Adams et al., 2018 ). Social isolationterm·dom also has effects, as low emotional support and social isolationterm·dom are clear risk factors for increased anxiety and depression ( Puigpinós-Riera et al., 2018 ; Alcaraz et al., 2020 ). Furthermore, social isolationterm·dom in people with cancerterm·key is a significant issue that could aggravate depressive symptoms and increase tumor activity owing to the decreased expression of brain-derived neurotrophic factors ( Borgi et al., 2020 ). Moreover, it can potentially contribute to the development of breast cancerterm·key through hormonal, angiogenic, and inflammatory markers and mediators ( Hinzey et al., 2016 ). Low or impaired quality of lifeterm·dom is a major consequenceterm·mth of social isolationterm·dom, and health-related quality of lifeterm·dom may be negatively affected by social isolationterm·dom ( Simonelli and Otto, 2017 ; Iannarino, 2018 ; Dahill et al., 2020 ; Martopullo et al., 2020 ; Dornan et al., 2021 ; Leung et al., 2021 ; Takemura et al., 2021 ).

Conceptual definition Based on the attributes, antecedentsterm·mth, and consequencesterm·mth identified in this analysis, we propose the following definition of social isolationterm·dom in people with cancerterm·key: Social isolationterm·dom in adults with cancerterm·key refers to individuals demonstrating behaviors and states of social avoidanceterm·key (e.g., avoiding contact with others and concealing one’s emotions) and experiencing specific negative affective experiences (e.g., feelings of lonelinessterm·dom). Social isolationterm·dom can result from cancer-related physiological changes, cognitive beliefsterm·dom, psychological well-being, unsatisfactory social supports or relationships, restrictions associated with receiving treatments, and social-level barriers. Social isolationterm·dom can result in low therapeutic compliance, poor health conditions, mental health problems, and low quality of lifeterm·dom.

Figure 2 illustrates the negative antecedentsterm·mth, attributes, and consequencesterm·mth associated with social isolationterm·dom in people with cancerterm·key.

Model of social isolationterm·dom concept in adults with cancerterm·key.

Discussion Significance of findings Clear and precise conceptual systems play a significant role in the development of nursing knowledge ( Tofthagen and Fagerstrom, 2010 ). Based on current knowledge, this is the first study to conceptualize social isolationterm·dom in adults with cancerterm·key. Previous studies have only provided an in-depth analysis of issues related to social isolationterm·dom in older adults ( Nicholson, 2009 ). Furthermore, studies have underscored the effects of social isolationterm·dom at the physiological level ( Friedler et al., 2015 ). However, limited studies in this regard focus on people with cancerterm·key, who are also affected severely by social isolationterm·dom. This may be why social isolationterm·dom in people with cancerterm·key has not been explained adequately using the social isolationterm·dom concepts from other populations. Therefore, it is necessary to clarify this concept in the cancerterm·key population. This concept analysisterm·key has established a set of attributes to define social isolationterm·dom in adults living with cancerterm·key. Using standardized language developed using the concept analysisterm·key procedure, nurses and physicians can assess social isolationterm·dom among cancerterm·key survivors and differentiate it from that among older adults and non-cancer survivors. It is crucial to recognize that social isolationterm·dom in cancerterm·key survivors is a multidimensional experience influenced by several factors, particularly cancer-related physiological changes.

Interpreting the results In this analysis, the attributes of social isolationterm·dom were classified into two categories, namely, behaviors and states of social avoidanceterm·key and negative affective experiences. Insufficient social networks and feelings of lonelinessterm·dom were the most frequent characteristics of social isolationterm·dom among the two categories. Table 3 indicates that only some of the included studies covered both categories. This may be owing to the varying cancerterm·key populations present in the included studies. Hence, the focus on social isolationterm·dom in this analysis also differed.

No consensus was reached on the definition of social isolationterm·dom in cancerterm·key populations. Compared to the behaviors and states of social avoidanceterm·key, the negative affective experience attributes were more challenging to identify. Studies indicate that the latter attribute, which includes perceived social isolationterm·dom and feelings of lonelinessterm·dom, is more harmful to mental health than the former ( Liu B et al., 2021 ; Liu Y et al., 2021 ). Several patients were not aware that they were socially isolated despite having restricted social networks ( Blinderman and Cherny, 2005 ; Tomaka et al., 2006 ). However, individuals can still feel lonely even if they are well-supported socially ( Tomaka et al., 2006 ). Thus, it can be suggested that subjective or perceived social isolationterm·dom warrants increased priority. During follow-up, nurses and physicians should pay close attention to the patient’s psychological changes and identify social isolationterm·dom early.

Identifying implications White’s heuristic model stipulates that individuals will reshape their ideal self-image when their appearance and/or physical function are damaged ( White, 2000 ). However, excessive expectations regarding their external image can lead to persistent and unpleasant emotions as well as social avoidance behaviorsterm·dom. Thus, people living with cancerterm·key may rebuild their ideal self-image after perceiving changes in appearance and physical function. However, owing to stigma, among other reasons, they could demonstrate compensatory behaviors to avoid social activities.

Notably, White’s heuristic model suggests that social isolationterm·dom could result from incorrect self-perception, such as negative self-evaluation and unrealistic expectations. Furthermore, this model can enable nurses and physicians to analyze the internal influencing factors of social isolationterm·dom among patients. Moreover, it suggests that nurses and physicians ought to predictably guide the establishment of improved self-cognition while providing psychological care to patients with cancerterm·key. It is imperative to address negative self-assessments among patients as soon as they exhibit social isolationterm·dom behavior. Social isolationterm·dom is a multidimensional experience, and its antecedentsterm·mth may comprise the aforementioned attributes; thus, future studies must provide an in-depth examination of the relationships among these attributes.

Identifying the attributes of social isolationterm·dom in adults with cancerterm·key has profound implications. Along with the common attributes (i.e., limitations in social networks and feelings of lonelinessterm·dom), living an abnormal life and concealing individual emotions have been identified as characteristics of behaviors and states of social avoidanceterm·key. The findings from this analysis illustrate the unique aspect of social isolationterm·dom associated with cancerterm·key. Upon our review ( Miaskowski et al., 2020 ; Morreale et al., 2020 ; Takemura et al., 2021 ), we also found that the measurement tools used to assess social isolationterm·dom vary across studies. This confirms a lack of consensus on the concept of social isolationterm·dom regarding cancerterm·key populations. Furthermore, it suggests that future research ought to explore and implement social isolationterm·dom assessment tools that can perform standardized scoring to facilitate nursing assessment, as well as increase the comparability of this indicator in the cancerterm·key population. In future research, antecedentterm·mth social health factors such as COVID-19 could enhance the complexity associated with the concept of social isolationterm·dom. Thus, researchers should consider the issue more comprehensively.

Limitations Several limitations and biases have been identified in this analysis, including the interpretations of the results and the possibility of an incomplete search of sources. Despite following the guidance of the inductive process underscored in Rodgers’ evolutionary method ( Rodgers, 2000 ), this analysis might contain bias. In an attempt to mitigate this, the process of data extraction was performed independently by two reviewers, and a third reviewer was consulted in case of a disagreement. While a systematic search was conducted, it is unlikely that it was comprehensive. Moreover, this concept analysisterm·key only included literature published in English and Chinese, as there is a more extensive volume of articles in these two languages.

Conclusion The findings from this concept analysisterm·key contribute to the understanding and clarity of social isolationterm·dom regarding adults with cancerterm·key. This analysis could be applied to developing cancer-specific assessment tools and measures that can facilitate early recognition of the requirements underlying psychosocial support and establish a conceptual foundation to mitigate social isolationterm·dom regarding clinical practice and research. Subjective, perceived social isolationterm·dom is of specific concern. Further studies are required to examine the relationships among attributes. Moreover, research mitigating social isolationterm·dom is needed to assist people living with cancerterm·key to improve ways of adapting to adversity throughout their experience.

Author contributions YL: conceptualization, methodology–data collection, methodology–data analysis, writing–original draft preparation, and writing–reviewing and editing. GH: resources and revision. MW: methodology–data collection and methodology–data analysis. LH: writing–review and editing and supervision. All authors contributed to the article and approved the submitted version.

Funding This work was supported by the Shanghai Association For Science and Tech (21002411300) and Innovation research team of high-level local universities in Shanghai (SHSMU-ZDCX20212802).

Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments We would like to thank Editage ( www.editage.cn ) for English language editing.

References