The Impact of Physical Symptoms on Depression and Quality of Life in Patients with Lung Cancer: The Moderating Effects of Illness Perceptions and Gender

The Impact of Physical Symptoms on Depression and Quality of Life in Patients with Lung Cancer: The Moderating Effects of Illness Perceptions and Gender | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of Physical Symptoms on Depression and Quality of Life in Patients with Lung Cancer: The Moderating Effects of Illness Perceptions and Gender Jinhuan Yang, Danni Dong, Gan He, Zhenghao Ge, Zhonglin Chen, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6265259/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Jun, 2025 Read the published version in Health and Quality of Life Outcomes → Version 1 posted 9 You are reading this latest preprint version Abstract Background Physical symptoms negatively affect lung cancer patients’ emotional well-being and quality of life. It remains understudied about what psychosocial factors may buffer the negative impact of physical symptoms. This study examines how illness perceptions moderate the impact of physical symptoms on depression and quality of life, and further considers gender differences. Methods This is a cross-sectional study. 316 lung cancer patients completed questionnaires measuring physical symptoms, depression, quality of life, and illness perceptions. Results Hierarchical regression analyses reveal significant two-way interactions between physical symptoms and perception of illness timeline on both depression and quality of life. Furthermore, we found significant three-way interactions among physical symptoms, illness perceptions, and gender. Simple slope analyses indicated that positive illness perceptions alleviated the negative effects of physical symptoms on depression and quality of life, particularly in females. Conclusions Therefore, it is essential to tailor the intervention to address the distinct psychosocial needs of male and female patients to enhance the intervention's effectiveness. Lung cancer Physical symptoms Depression Quality of life Illness perceptions Figures Figure 1 Figure 2 Background According to the 2020 Global Cancer Report, the incidence and mortality rates of lung cancer rank first in China [ 1 ]. Lung cancer-related physical symptoms significantly impair patients’ emotional well-being and quality of life [2 3]. Heavy symptom burden reduces patients’ treatment compliance, diminishes treatment outcomes, and leads to poor disease prognosis [4 5]. Given these challenges, it is crucial to investigate potential psychosocial factors that may buffer the negative impact of physical symptoms on patients’ emotional well-being and quality of life. The present study aimed to investigate how patients’ illness perceptions moderate the association of physical symptoms with depression and quality of life, and further explore whether this moderating effect would further depend on patients’ gender. Existing literature has documented an association between physical symptoms and depression, as well as quality of life, in lung cancer patients [6 7]. According to the Common-Sense Model of Illness Self-Regulation [ 8 – 10 ], illness perceptions are posited as important mediators in this association. Physical symptoms can trigger negative illness perceptions, such as the belief that the disease is difficult to control or will significantly impact their life. The negative illness perceptions can lead to depression, fear of cancer recurrence, and poor quality of life. Illness perceptions refer to patients’ cognitive interpretations of the illness, shaped by their personal experiences, knowledge, values, beliefs, and needs [ 11 ]. Although the mediating role of illness perceptions in the association of physical symptoms with depression and quality of life has been well-established in the literature [8 9 12], it remains unknown whether individual differences in illness perceptions might moderate this association. Individuals’ perceptions of illness are shaped by a variety of social and individual factors, such as personality, life experience, cultural beliefs, and access to social support [ 13 ]. These perceptions vary significantly across individuals. Compared to those with more negative illness perceptions, individuals with more positive illness perceptions may interpret their physical symptoms in a less threatening manner [ 14 ]. For example, they may perceive their symptoms as controllable, reducing the perceived threat to their well-being. This positive appraisal may enhance individuals’ ability to cope with the challenges posed by the illness, foster their confidence in their treatment and recovery [ 15 ], and hence buffer the negative effect of physical symptoms on patients’ emotional well-being and quality of life. In contrast, patients with more negative illness perceptions tend to report higher levels of anxiety and depressive symptoms, as well as poorer self-rated health [ 16 ]. However, whether illness perceptions moderate this association remains unclear. Existing literature has demonstrated that a certain variable that acts as a mediator in a correlation may also serve as a moderating in the same relationship [17 18]. For example, in a cross-sectional study on 249 undergraduate students, protective behavioral strategies mediated the relationship between self-regulation and drinking problems; at the same time, the authors also found that behavioral strategies moderated the relationship between self-regulation and drinking problems, with the use of protective behavioral strategies reducing the negative consequences of drinking for individuals with poor self-regulation [ 17 ]. Thus, individual differences in illness perceptions may also moderate the association between physical symptoms and depression, as well as quality of life. Current study This cross-sectional study aimed to examine the moderating effect of illness perceptions on the association between physical symptoms and depression, as well as quality of life, in lung cancer patients. We hypothesized that patients with more positive illness perceptions would experience fewer negative effects of physical symptoms on depression and quality of life compared to those with more negative illness perceptions. Furthermore, we explored whether the moderating effect of illness perceptions would further depend on patients’ gender. Previous research has shown that when coping with cancer-related stress, female patients exhibit a greater tendency to seek social support from their social networks [ 19 ] and are more inclined to express their emotions compared to their male counterparts [ 20 ]. This active engagement in support-seeking and emotional expression may help female patients make sense of the disease, thereby facilitating cognitive processing of their perceptions of the illness. As a result, the buffering effect of illness perceptions is likely more pronounced among female cancer patients than male cancer patients. Methods Study design and participants From July to September 2021, the study was carried out at a specialized tertiary hospital in Shanghai, China. The hospital is well known for its treatment and research in lung cancer, so it attracts patients in need from all over the country. Upon patients’ admission to the oncology department, the research team conducted a thorough review of the patient’s medical records to screen for eligibility. Patients who met the screening criteria were approached and informed about the study. Eligible and willing participants who provided their consent were enrolled and completed a cross-sectional survey measuring demographic information, clinical characteristics, and the variables of interest. This study was approved by the ethics committee at the School of Public Health at Shanghai Jiao Tong University School of Medicine (SJUPN-201915). All participants signed informed consent. The inclusion criteria included: a) diagnosed with lung cancer through cytological or histological examination; b) age ≥ 18 years old; and c) expected survival time of three months or more. The exclusion criteria included: a) severe mental disorders or cognitive impairments; b) poor language ability with inability to understand the study materials. A total of 350 patients were initially recruited for the survey. Ultimately, 316 patients agreed to participate and completed the questionnaire survey, resulting in a response rate of 90.3% (n = 350). The enrolled patients ranged from 24 to 81 years old (M = 61.87, SD = 9.57). Of this group, 74.7% (n = 316) were male, and 81.6% (n = 316) had an education level of high school or below. The average time since cancer diagnosis was 14.12 (SD = 22.16) months. Additional demographic and clinical characteristics are reported in Table 1 . Table 1 Demographic and clinical characteristics of 316 lung cancer patients Variable M (SD) Frequency (%) a Age (years) 61.87(9.57) Gender Male 236 74.7 Female 80 25.3 Education Elementary school or lower 83 26.3 Junior high school 88 27.8 Senior high school 87 27.5 College or higher 58 18.4 Marital status Married 287 90.8 Single/divorced/widowed 29 9.2 Percentage of family income spent on cancer treatment for the past year 100% 57 18.0 Occupation Full-time 22 7.0 Part-time 1 0.3 Sick leave/unemployed/retired 282 89.2 Months since diagnosis (month) 14.12(22.16) Cancer stage Ⅰ 21 6.6 Ⅱ 14 4.4 Ⅲ 83 26.3 Ⅳ 163 51.6 Treatment received Chemotherapy 254 80.4 Surgery 106 33.5 Radiotherapy 53 16.8 Targeted therapy 117 37.0 a Percentages may not add up to 100% because of missing data Measures Physical symptoms Physical symptoms were assessed via the Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire for Lung Cancer Module (QOL-LC13) [21 22], which comprises 13 items designed to assess 9 physical symptoms associated with lung cancer or its treatment, such as coughing, dyspnea, and chest pain. In this study, patients rated the severity of symptoms experienced in the past week on a scale ranging from (1) not at all to (4) very much. Because item 13 assesses pain relief with painkillers, the total score of the initial 12 items was used to assess the severity of physical symptoms, with higher scores indicating greater symptom severity. The internal reliability of the 12-item scale is 0.72 in this study. Illness perceptions Illness perceptions were evaluated using the Brief Illness Perception Questionnaire (BIPQ) [23 24]. This questionnaire consists of 9 items, with each item representing an independent subscale designed to evaluate patients' perception across various dimensions of their illness. In this study, the scoring for the four illness perception dimensions we utilized is as follows: 1) Illness consequences (How much does your illness affect your life?) ranging from (0) no affect at all to (10) severely affects my life; 2) Illness timeline (How long do you think your illness will continue?) ranging from (0) a very short time to (10) forever ; 3) Personal control (How much do you feel you can control your illness?) ranging from (0) absolutely no control to (10) extreme amount of control ; and 4) Treatment control (How much do you think the treatment you are receiving, such as medication, can help control your illness?) ranging from (0) not at all to (10) extremely helpful . Depression Depression was assessed using the depression subscale of the Chinese version of the Hospital Anxiety and Depression Scale (HADS) [25 26]. The depression subscale comprises 7 items, scored on a 4-point scale. Patients rated the severity of each symptom they experienced over the past week. Regarding the depression subscale, similar to our previous published study [ 27 ], the item-total correlation for item 10, “I have lost interest in my appearance” (r = 0.07), was significantly lower than the correlations for the other items in the subscale (ranging from 0.31 to 0.57). Furthermore, removing item 10 increased the internal reliability of the depression subscale from 0.65 to 0.74. Therefore, we decided to exclude item 10 and impute its score with the average score of the remaining 6 items. Based on the results of a previous validation study conducted in Chinese cancer patients [ 28 ], a total score of 8 was established as the cutoff point for probable diagnoses of depressive disorders. Quality of life The 5-level EQ-5D version (EQ-5D-5L) was used to assess the quality of life [ 29 ]. The EQ-5D descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, each with 5 levels ranging from (1) no problems to (5) extreme problems . Health utility values for the patients were calculated based on the Chinese residents' health preference model [ 30 ]. Higher utility values represent better quality of life for patients. In the study, the internal reliability of the scale is 0.68. Statistical Analysis Statistical analyses were performed using SPSS 26.0. Preliminary analyses included descriptive statistical analyses and correlation analyses among variables of major interest. Pearson correlations were performed to assess the associations between the variables of interest and sample characteristics to identify potential covariates to be controlled for in subsequent analyses. To test the moderation of four dimensions of illness perceptions, we conducted four hierarchical multiple regression models, one for each dimension of illness perceptions, separately. In step 1, potential covariates and the main effects of physical symptoms and illness perception were entered. In Step 2, the two-way interaction terms (physical symptoms × illness perception, physical symptoms × gender, illness perception × gender) were entered. In Step 3, we entered the three-way interactions among gender, illness perception, and physical symptoms. All variables were centered before the regression analyses to reduce multicollinearity. Results Preliminary analyses Descriptive statistics and bivariate correlations of study variables were reported in Table 2. The average severity of physical symptoms was 166.72 (SD = 127.66). The average depression score was 3.11 (SD = 3.10). In this sample, 9.5% (n = 316) of patients were above the threshold for probable depressive disorder. As was shown in Table 2, there was a negative correlation between education level and depression (β = -0.13, P = 0.018), as well as a negative correlation between age and quality of life (β = -0.12, P = 0.046). Therefore, education level and age were included as covariates in subsequent hierarchical regression analyses. Table 2. Descriptive statistics and correlations of study variables Variable Mean SD 1 2 3 4 5 6 7 8 9 1. Physical symptoms 166.72 127.66 1.00 — — — — — — — — 2. Illness consequences 5.78 3.13 0.26 ** 1.00 — — — — — — — 3. Illness timeline 5.71 3.23 0.21 ** 0.26 ** 1.00 — — — — — — 4. Personal control 5.96 2.92 -0.20 ** -0.20 ** 0.00 1.00 — — — — — 5. Treatment control 7.65 2.28 -0.24 ** -0.10 -0.10 0.31 ** 1.00 — — — — 6. Depression 3.11 3.10 0.33 ** 0.25 ** 0.21 ** -0.22 ** -0.22 ** 1.00 — — — 7. Quality of life 0.88 0.16 -0.49 ** -0.26 ** -0.19 ** 0.17 ** 0.18 ** -0.34 ** 1.00 — — 8. Age 61.87 9.57 0.13 * -0.06 0.10 -0.04 -0.07 0.08 -0.13 * 1.00 — 9. Education — — -0.08 0.05 -0.04 0.04 0.05 -0.12 * 0.03 -0.30 ** 1.00 * P < 0.05, ** P < 0.01 Regression Analyses Depression as the outcome variable Two-way interaction between physical symptoms and illness perceptions. Table 3 presents the results of hierarchical regression analyses with four illness perceptions as moderators. There was a significant physical symptoms × illness timeline two-way interaction (β = 0.12, P = 0.028). As recommended by Aiken and West [ 31 ], a simple slope test was conducted to compare the association between physical symptoms and depression at high vs. low rating illness timeline. As shown in Figure. 1a, patients with higher illness timeline perception scores exhibited a stronger correlation between physical symptoms and depression (β = 0.42, P < 0.001) compared to those with lower scores (β = 0.18, P = 0.029). These results suggested that the effect of physical symptoms on depression was relatively more pronounced in patients perceived with a longer illness timeline. Table 3. Hierarchical regression analyses of physical symptoms, illness perceptions, gender, and their interactions on depression β R 2 ΔR 2 df F Illness consequences Step 1 0.15 0.15 298 13.36 *** Education -0.11 Physical symptoms 0.28 *** Illness consequences 0.18 ** Gender -0.06 Step 2 0.17 0.01 295 1.68 Physical symptoms × illness consequences -0.04 Physical symptoms × gender -0.13 Illness consequences × gender -0.02 Step 3 0.18 0.020 294 6.46 * Physical symptoms × illness consequences × gender 0.17 * Illness timeline Step 1 0.14 0.14 276 11.41 *** Education -0.090 Physical symptoms 0.30 *** Illness timeline 0.14 * Gender -0.05 Step 2 0.17 0.03 273 3.20 * Physical symptoms × illness timeline 0.12 * Physical symptoms × gender -0.130 Illness timeline × gender -0.02 Step 3 0.15 0.00 272 0.02 Physical symptoms × illness timeline × gender -0.01 Personal control Step 1 0.14 0.14 282 11.91 *** Education -0.09 Physical symptoms 0.30 *** Personal control -0.15 ** Gender -0.05 Step 2 0.16 0.01 279 1.21 Physical symptoms × personal control 0.03 Physical symptoms × gender -0.12 Personal control× gender 0.03 Step 3 0.16 0.00 278 0.32 Physical symptoms × personal control × gender 0.04 Treatment control Step 1 0.14 0.14 290 11.83 *** Education -0.09 Physical symptoms 0.29 *** Treatment control -0.14 * Gender -0.05 Step 2 0.16 0.02 287 1.76 Physical symptoms × treatment control 0.05 Physical symptoms × gender -0.12 Treatment control × gender 0.06 Step 3 0.17 0.01 286 3.01 Physical symptoms × treatment control × gender -0.13 * P < 0.05, ** P < 0.01, *** P < 0.001 Three-way interaction among physical symptoms, illness perceptions, and gender. There was a significant physical symptoms × illness consequences × gender three-way interaction (β = 0.17, P = 0.012). Simple slope test in Figure. 1b and Figure. 1c showed that among female patients with low levels of illness consequences perception, physical symptoms were not associated with depression (β= -0.02, P = 0.910). Among female patients with high levels of illness consequences perception, physical symptoms were positively associated with depression (β = 0.27, P = 0.042). In contrast, in male patients, regardless of whether they had high or low scores in illness consequences perception, there was a positive correlation between physical symptoms and depression (P < 0.05). The above results suggested that positive illness consequences perception could buffer the negative effects of physical symptoms on depression, but this buffer effect was only significant for female patients. Quality of life as the outcome variable Two-way interaction between physical symptoms and illness perceptions. Table 4 presents that there is a significant physical symptoms × illness timeline two-way interaction (β= -0.13, P = 0.010). Simple slope test in Figure. 2a showed that for patients with higher illness timeline perception scores, the correlation between physical symptoms and quality of life (β= -0.61, P < 0.001) was higher than for patients with lower illness timeline perception scores (β= -0.34, P < 0.001). These results suggested that the effect of physical symptoms on quality of life was relatively more salient for patients with a more negative perception of the illness timeline. Table 4. Hierarchical regression analyses of physical symptoms, illness perceptions, gender, and their interactions on quality of life β R 2 ΔR 2 df F Illness consequences Step 1 0.27 0.27 305 28.21 *** Age -0.09 Physical symptoms -0.43 *** Illness consequences -0.15 ** Gender -0.10 Step 2 0.28 0.01 302 0.99 Physical symptoms × illness consequences -0.06 Physical symptoms × gender -0.05 Illness consequences × gender -0.05 Step 3 0.28 0.00 301 0.00 Physical symptoms × illness consequences × gender -0.00 Illness timeline Step 1 0.26 0.26 281 24.26 *** Education -0.07 Physical symptoms -0.46 *** Illness timeline -0.09 Gender -0.10 Step 2 0.28 0.02 278 2.51 Physical symptoms × illness timeline -0.13 * Physical symptoms × gender -0.07 Illness timeline × gender 0.01 Step 3 0.28 0.00 277 0.93 Physical symptoms × illness timeline × gender 0.06 Personal control Step 1 0.26 0.26 287 25.54 *** Education -0.08 Physical symptoms -0.46 *** Personal control 0.08 Gender -0.10 Step 2 0.26 0.01 284 0.97 Physical symptoms × personal control 0.07 Physical symptoms × gender -0.07 Personal control× gender 0.02 Step 3 0.28 0.01 283 5.30 * Physical symptoms × personal control × gender 0.14 * Treatment control Step 1 0.25 0.25 292 24.91 *** Education -0.08 Physical symptoms -0.46 *** Treatment control 0.07 Gender -0.10 * Step 2 0.26 0.01 289 0.70 Physical symptoms × treatment control 0.05 Physical symptoms × gender -0.08 Treatment control × gender 0.01 Step 3 0.27 0.02 288 5.79 * Physical symptoms × treatment control × gender 0.17 * * P < 0.05, ** P < 0.01, *** P < 0.001 Three-way interaction among physical symptoms, illness perceptions, and gender. Table 4 presents that physical symptoms × personal control × gender interaction (β = 0.14, P = 0.022) and physical symptoms × treatment control × gender interaction (β = 0.17, P = 0.017) are significant. Simple slope tests for significant physical symptoms × personal control × gender three-way interaction in Figure. 2b and Figure. 2c showed that, among female patients, physical symptoms were not significantly correlated with quality of life for those with higher perceived personal control scores (β= -0.20, P = 0.149), whereas for those with lower perceived personal control scores, physical symptoms were negatively correlated with quality of life (β= -0.86, P < 0.001). In contrast, among male patients, physical symptoms were negatively correlated with quality of life regardless of perceived personal control scores (P < 0.05). Simple slope tests for significant physical symptoms × treatment control × gender three-way interaction in Figure. 2d and Figure. 2e showed that, among female patients, the correlation between physical symptoms and quality of life was higher (β= -0.97, P < 0.001) for those with lower perceived treatment control scores than for those with higher perceived treatment control scores (β= -0.33, P = 0.005). In contrast, among male patients, physical symptoms were negatively associated with quality of life regardless of high or low perceived treatment control scores (P < 0.05). The above results suggested that the buffering effect of positive illness perception (i.e., perceptions of personal control and treatment control of illness) was more salient for female patients. Discussion The present study takes the first step in investigating the moderating role of illness perceptions on the association of physical symptoms with depression and quality of life in patients with lung cancer. We also examined the gender differences in this moderating effect. Our findings are generally in line with the hypotheses. We found that a positive perception of the illness timeline buffered the negative impact of physical symptoms on depression and quality of life. Moreover, the buffering effects of the perception of illness consequences, personal control, and treatment control were significant only in female patients. Having more positive perceptions of the illness timeline (i.e., perceiving the illness timeline as short) helps alleviate the negative impact of physical symptoms on depression and quality of life. Patients with positive perceptions of their illness tend to perceive the illness as temporary, controllable, and having a minimal impact on their lives, with effective treatment options. Recent research has uncovered a positive association between positive illness perceptions and milder depression, along with an improved quality of life [ 32 ]. These patients with positive perceptions tend to view the burden of symptoms as a relatively minor threat to their overall well-being [ 14 ]. This diminished perceived threat instills confidence in patients, enabling them to take effective measures in coping with their illness, thus mitigating the negative impact of physical symptoms on their emotional well-being and quality of life. In contrast, holding a negative attitude toward the illness may lead patients to be more sensitive to bodily discomfort, potentially escalating into a catastrophic perception of physical symptoms, thereby exacerbating depression and reducing the quality of life [ 33 ]. It is also plausible that individuals with a positive illness perception are more inclined to seek assistance from medical professionals when faced with symptoms [ 34 ]. Support from healthcare providers and other social support networks can enhance patients' confidence in managing the illness, allowing for a more effective handling of physical symptoms. Moreover, we found that the buffering effect of illness perception was only significant among female patients. One potential explanation may be related to gender differences in stress coping. Research has indicated that female cancer patients are more inclined to seek support from social networks [ 19 ]. Besides, female cancer patients show greater emotional expressivity than male patients [ 20 ]. Emotionally expressive coping has also been linked to improved psychological adjustment and physical health among breast cancer patients [ 35 ]. Through seeking support and expressing emotions with social partners, female patients likely have more opportunities to reappraise their disease from a more positive perspective. Consequently, the buffering effect of positive illness perceptions may be more pronounced among female patients. More studies are needed to confirm this finding. Implication Our findings have implications for the development of interventions for managing symptoms and improving psychological adjustment of lung cancer patients. The results indicate that facilitating positive illness perceptions may be beneficial for reducing the negative impact of physical symptoms on depression and quality of life, especially for female patients. Thus, future interventions on lung cancer symptom management should incorporate a psychoeducation component on how to develop positive illness perceptions. Moreover, given the finding that the buffering effect of illness perception is more salient among female patients, the design of the psychoeducation should also be tailored to the psychosocial needs of female patients. For example, nurses providing patients with health education about the disease and personalized emotional support can improve symptoms, self-management, and quality of life [ 36 ]. Mindfulness-based cognitive therapy aims to promote positive illness perceptions and beliefs that can reduce the level of negative illness perceptions, and improve psychological distress and quality of life [ 37 ]. Limitations The present study has several limitations. First, the study used a cross-sectional design, which resulted in correlational findings, making it impossible to conclude the association between physical symptoms, depression, and quality of life. Subsequent longitudinal studies are needed for further validation. Second, there is the reason for caution over the findings’ generalizability to other patient stages, given that the bulk of the study’s patients are in Stage Ⅲ & Ⅳ. Further studies with a wider range of phases are necessary to confirm and extrapolate the results for different stages of the disease. Third, although the study was carried out in a renowned hospital that saw patients from all across the nation, the sample’s representativeness is limited because the study was conducted at a single center. Future multi-center studies that include a more diverse patient population may improve the external validity of the results. Conclusions In conclusion, our study has demonstrated that facilitating positive illness perceptions can alleviate the negative impact of physical symptoms on depression and quality of life. Moreover, we found this moderating effect of illness perception was more salient in female patients. Future psychological interventions could target patients' illness perceptions in a personalized manner, employing positive psychological and behavioral strategies to help patients better cope with the effects of the disease. Declarations Ethics approval and consent to participate This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the ethics committee at the School of Public Health at Shanghai Jiao Tong University School of Medicine (SJUPN-201915). All participants signed informed consent. Consent for publication The findings described in this document have not been previously published, and none of the authors are currently submitting them to another publisher for consideration. Competing interests The authors declare that they have no conflict of interest. Funding This study was supported by the National Natural Science Foundation of China [grant numbers: 72004133, 71874111]; and The China Medical Board Open Competition Grants Program [grant number: 22–479]. Author Contribution Qiao Chu and Yaping He conceived and designed the study. Danni Dong, Gan He, and Zhenghao Ge collected the data. Zhonglin Chen, Chenyan Han, and Yi Zhao managed the project. Jinhuan Yang conducted the statistical analysis and modeling and drafted the manuscript. Qiao Chu guided the study and oversaw manuscript evaluation and revision. Acknowledgement The authors acknowledge the assistance of the staff in the Shanghai Chest Hospital in conducting the survey. Availability of data and materials The data are not publicly available due to this data containing information that could compromise the privacy of research participants. The data that support the findings of this study are available from the corresponding author upon reasonable request. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 2021;71(3):209–49. Andersen BL, Valentine TR, Lo SB, Carbone DP, Presley CJ, Shields PG. 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Psychometric assessment of the Chinese version of the brief illness perception questionnaire in breast cancer survivors. PLoS ONE. 2017;12(3):e0174093. Li Q, Lin Y, Hu C, Xu Y, Zhou H, Yang L, et al. The Chinese version of hospital anxiety and depression scale: Psychometric properties in Chinese cancer patients and their family caregivers. Eur J Oncol nursing: official J Eur Oncol Nurs Soc. 2016;25:16–23. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta psychiatrica Scandinavica. 1983;67(6):361–70. Chen Z, He G, Zhao Y, Han C, Xu L, Jian H, et al. Symptom burden and emotional distress in advanced lung cancer: the moderating effects of physicians' communication skills and patients' disease understanding. Supportive Care Cancer: Official J Multinational Association Supportive Care Cancer. 2022;30(11):9497–505. Wang HS-H, Feng A-C, Chiu C-Y, Shen J-F, Lin Y-J et al. The HADS and the DT for screening psychosocial distress of cancer patients in Taiwan. 2011;20(6):639–46. Wang H, Kindig DA, Mullahy J. Variation in Chinese population health related quality of life: results from a EuroQol study in Beijing, China. Qual life research: Int J Qual life aspects Treat care rehabilitation. 2005;14(1):119–32. Luo N, Liu G, Li M, Guan H, Jin X, Rand-Hendriksen K. Estimating an EQ-5D-5L Value Set for China. Value Health: J Int Soc Pharmacoeconomics Outcomes Res. 2017;20(4):662–9. Aiken LS, West SG. Multiple regression: Testing and interpreting interactions. Thousand Oaks, CA, US: Sage Publications, Inc; 1991. xi, 212-xi, p. Ünal Ö, Akyol Y, Tander B, Ulus Y, Terzi Y, Kuru Ö. The relationship of illness perceptions with demographic features, pain severity, functional capacity, disability, depression, and quality of life in patients with chronic low back pain. Turk J Phys Med Rehabil. 2019;65(4):301–8. de Rooij BH, Thong MSY, van Roij J, Bonhof CS, Husson O, Ezendam NPM. Optimistic, realistic, and pessimistic illness perceptions; quality of life; and survival among 2457 cancer survivors: the population-based PROFILES registry. Cancer. 2018;124(17):3609–17. Asai K, Hatamochi C, Minamimura F. Association Between Illness Perception and Care-Seeking Intention in Patients With Chronic Heart Failure. Clin Nurs Res. 2023;32(3):669–76. Stanton AL, Danoff-Burg S, Cameron CL, Bishop M, Collins CA, Kirk SB, et al. Emotionally expressive coping predicts psychological and physical adjustment to breast cancer. J Consult Clin Psychol. 2000;68(5):875–82. Weldam SWM, Schuurmans MJ, Zanen P, Heijmans MJWM, Sachs APE, Lammers J-WJ. The effectiveness of a nurse-led illness perception intervention in COPD patients: a cluster randomised trial in primary care. ERJ Open Res. 2017;3(4). Dalili Z, Bayazi MH. The effectiveness of Mindfulness-Based Cognitive Therapy on the illness perception and Psychological Symptoms in patients with Rheumatoid Arthritis. Complement Ther Clin Pract. 2019;34:139–44. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Jun, 2025 Read the published version in Health and Quality of Life Outcomes → Version 1 posted Editorial decision: Revision requested 29 Apr, 2025 Reviews received at journal 24 Apr, 2025 Reviews received at journal 09 Apr, 2025 Reviewers agreed at journal 08 Apr, 2025 Reviewers agreed at journal 05 Apr, 2025 Reviewers invited by journal 03 Apr, 2025 Editor assigned by journal 23 Mar, 2025 Submission checks completed at journal 23 Mar, 2025 First submitted to journal 19 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6265259","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":443233779,"identity":"9e3a573f-6588-460c-8bbb-f3ce77628521","order_by":0,"name":"Jinhuan Yang","email":"","orcid":"","institution":"School of Public Health, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jinhuan","middleName":"","lastName":"Yang","suffix":""},{"id":443233780,"identity":"7fc438b7-2e95-40e0-bd6b-e82b2d84be9f","order_by":1,"name":"Danni Dong","email":"","orcid":"","institution":"School of Public Health, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Danni","middleName":"","lastName":"Dong","suffix":""},{"id":443233781,"identity":"d84fff31-815c-4627-b0e2-6250f07d33d4","order_by":2,"name":"Gan He","email":"","orcid":"","institution":"School of Public Health, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Gan","middleName":"","lastName":"He","suffix":""},{"id":443233782,"identity":"c10dfdee-0cd2-4831-8818-1e1dd85001b9","order_by":3,"name":"Zhenghao Ge","email":"","orcid":"","institution":"School of Public Health, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Zhenghao","middleName":"","lastName":"Ge","suffix":""},{"id":443233783,"identity":"c233ac6e-a657-47aa-872d-1bf51b610017","order_by":4,"name":"Zhonglin Chen","email":"","orcid":"","institution":"Shanghai Chest Hospital, Shanghai Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Zhonglin","middleName":"","lastName":"Chen","suffix":""},{"id":443233784,"identity":"1cf1ef60-0acc-4a51-81bf-2abe7e6e5bf1","order_by":5,"name":"Chenyan Han","email":"","orcid":"","institution":"Shanghai Chest Hospital, Shanghai Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Chenyan","middleName":"","lastName":"Han","suffix":""},{"id":443233786,"identity":"57caf341-b07a-459c-9dac-85aba7fdb9f8","order_by":6,"name":"Yi Zhao","email":"","orcid":"","institution":"Shanghai Chest Hospital, Shanghai Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Zhao","suffix":""},{"id":443233787,"identity":"5e992f01-c5df-4b4a-ab0a-23966d673815","order_by":7,"name":"Yaping He","email":"","orcid":"","institution":"School of Public Health, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yaping","middleName":"","lastName":"He","suffix":""},{"id":443233788,"identity":"0e49c3a7-07f2-492b-8546-6e579dd876f5","order_by":8,"name":"Qiao Chu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYDACZiBmbGCQY5CA8IFsIrUYk6AFqiyxgWgtfMeZHz74ueNw+vzZ7U838zDYyG44wPzsAT4tkofZjA17zxzO3XDnjNltHoY04w0H2MwN8GkxOMxgJs3YBtQikcMG1HI4ccMBHjYJ/FrYv4G0pMvPSH8G1PKfGC08YFsSGG4kgBx2gLAWycM8xYa9bemGG27kmN2cY5BsPPMwmxleLXznj2988LPNWh7ksBtvKuxk+443P8OrheEAqjsZIJFLgpZRMApGwSgYBVgAAMFwS69O5iltAAAAAElFTkSuQmCC","orcid":"","institution":"School of Public Health, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Qiao","middleName":"","lastName":"Chu","suffix":""}],"badges":[],"createdAt":"2025-03-20 01:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6265259/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6265259/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12955-025-02395-7","type":"published","date":"2025-06-23T15:57:22+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82131586,"identity":"9b036f58-084e-437c-b27c-d1f3e7d3525d","added_by":"auto","created_at":"2025-05-07 05:36:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":122629,"visible":true,"origin":"","legend":"\u003cp\u003eThe two-way interaction effect of illness timeline perception and physical symptoms on depression (a); the three-way interaction effect of physical symptoms × illness consequences × gender on depression (b, c)\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6265259/v1/e80552e7a8555980fca6ef64.jpg"},{"id":82130623,"identity":"ca85d150-1558-4fcf-9644-9454e9b0df48","added_by":"auto","created_at":"2025-05-07 05:28:51","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":172052,"visible":true,"origin":"","legend":"\u003cp\u003eThe two-way interaction effect of illness timeline perception and physical symptoms on quality of life (a); the three-way interaction effect of physical symptoms × personal control × gender on quality of life (b, c); the three-way interaction effect of physical symptoms × treatment control × gender on quality of life (d, e)\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6265259/v1/0b59ec3829bc52c70ea3e3e5.jpg"},{"id":85686145,"identity":"c37568da-f891-40ee-8587-576f3895e4c6","added_by":"auto","created_at":"2025-06-30 16:03:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1420418,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6265259/v1/f7e21a1f-0899-4428-9b81-6a772b4f4048.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of Physical Symptoms on Depression and Quality of Life in Patients with Lung Cancer: The Moderating Effects of Illness Perceptions and Gender","fulltext":[{"header":"Background","content":"\u003cp\u003eAccording to the 2020 Global Cancer Report, the incidence and mortality rates of lung cancer rank first in China [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Lung cancer-related physical symptoms significantly impair patients’ emotional well-being and quality of life [2 3]. Heavy symptom burden reduces patients’ treatment compliance, diminishes treatment outcomes, and leads to poor disease prognosis [4 5]. Given these challenges, it is crucial to investigate potential psychosocial factors that may buffer the negative impact of physical symptoms on patients’ emotional well-being and quality of life. The present study aimed to investigate how patients’ illness perceptions moderate the association of physical symptoms with depression and quality of life, and further explore whether this moderating effect would further depend on patients’ gender.\u003c/p\u003e \u003cp\u003eExisting literature has documented an association between physical symptoms and depression, as well as quality of life, in lung cancer patients [6 7]. According to the Common-Sense Model of Illness Self-Regulation [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], illness perceptions are posited as important mediators in this association. Physical symptoms can trigger negative illness perceptions, such as the belief that the disease is difficult to control or will significantly impact their life. The negative illness perceptions can lead to depression, fear of cancer recurrence, and poor quality of life. Illness perceptions refer to patients’ cognitive interpretations of the illness, shaped by their personal experiences, knowledge, values, beliefs, and needs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the mediating role of illness perceptions in the association of physical symptoms with depression and quality of life has been well-established in the literature [8 9 12], it remains unknown whether individual differences in illness perceptions might moderate this association. Individuals’ perceptions of illness are shaped by a variety of social and individual factors, such as personality, life experience, cultural beliefs, and access to social support [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These perceptions vary significantly across individuals. Compared to those with more negative illness perceptions, individuals with more positive illness perceptions may interpret their physical symptoms in a less threatening manner [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. For example, they may perceive their symptoms as controllable, reducing the perceived threat to their well-being. This positive appraisal may enhance individuals’ ability to cope with the challenges posed by the illness, foster their confidence in their treatment and recovery [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and hence buffer the negative effect of physical symptoms on patients’ emotional well-being and quality of life. In contrast, patients with more negative illness perceptions tend to report higher levels of anxiety and depressive symptoms, as well as poorer self-rated health [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, whether illness perceptions moderate this association remains unclear.\u003c/p\u003e \u003cp\u003eExisting literature has demonstrated that a certain variable that acts as a mediator in a correlation may also serve as a moderating in the same relationship [17 18]. For example, in a cross-sectional study on 249 undergraduate students, protective behavioral strategies mediated the relationship between self-regulation and drinking problems; at the same time, the authors also found that behavioral strategies moderated the relationship between self-regulation and drinking problems, with the use of protective behavioral strategies reducing the negative consequences of drinking for individuals with poor self-regulation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Thus, individual differences in illness perceptions may also moderate the association between physical symptoms and depression, as well as quality of life.\u003c/p\u003e\n\u003ch3\u003eCurrent study\u003c/h3\u003e\n\u003cp\u003eThis cross-sectional study aimed to examine the moderating effect of illness perceptions on the association between physical symptoms and depression, as well as quality of life, in lung cancer patients. We hypothesized that patients with more positive illness perceptions would experience fewer negative effects of physical symptoms on depression and quality of life compared to those with more negative illness perceptions. Furthermore, we explored whether the moderating effect of illness perceptions would further depend on patients’ gender.\u003c/p\u003e \u003cp\u003ePrevious research has shown that when coping with cancer-related stress, female patients exhibit a greater tendency to seek social support from their social networks [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and are more inclined to express their emotions compared to their male counterparts [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This active engagement in support-seeking and emotional expression may help female patients make sense of the disease, thereby facilitating cognitive processing of their perceptions of the illness. As a result, the buffering effect of illness perceptions is likely more pronounced among female cancer patients than male cancer patients.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e\n\n\n\n \n\n "},{"header":"Methods","content":"\u003ch2\u003eStudy design and participants\u003c/h2\u003e\u003cp\u003eFrom July to September 2021, the study was carried out at a specialized tertiary hospital in Shanghai, China. The hospital is well known for its treatment and research in lung cancer, so it attracts patients in need from all over the country. Upon patients’ admission to the oncology department, the research team conducted a thorough review of the patient’s medical records to screen for eligibility. Patients who met the screening criteria were approached and informed about the study. Eligible and willing participants who provided their consent were enrolled and completed a cross-sectional survey measuring demographic information, clinical characteristics, and the variables of interest. This study was approved by the ethics committee at the School of Public Health at Shanghai Jiao Tong University School of Medicine (SJUPN-201915). All participants signed informed consent.\u003c/p\u003e\u003cp\u003eThe inclusion criteria included: a) diagnosed with lung cancer through cytological or histological examination; b) age ≥ 18 years old; and c) expected survival time of three months or more. The exclusion criteria included: a) severe mental disorders or cognitive impairments; b) poor language ability with inability to understand the study materials. A total of 350 patients were initially recruited for the survey. Ultimately, 316 patients agreed to participate and completed the questionnaire survey, resulting in a response rate of 90.3% (n = 350). The enrolled patients ranged from 24 to 81 years old (M = 61.87, SD = 9.57). Of this group, 74.7% (n = 316) were male, and 81.6% (n = 316) had an education level of high school or below. The average time since cancer diagnosis was 14.12 (SD = 22.16) months. Additional demographic and clinical characteristics are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical characteristics of 316 lung cancer patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM (SD)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (%) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.87(9.57)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e236\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.7\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary school or lower\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior high school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.5\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege or higher\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.4\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e287\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.8\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle/divorced/widowed\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercentage of family income spent on cancer treatment for the past year\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 50%\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.8\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50–100%\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.2\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 100%\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-time\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart-time\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSick leave/unemployed/retired\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e282\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89.2\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonths since diagnosis (month)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.12(22.16)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer stage\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅠ\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅡ\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅢ\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅣ\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51.6\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment received\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e254\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80.4\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.5\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiotherapy\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTargeted therapy\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003e Percentages may not add up to 100% because of missing data\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003ch3\u003eMeasures\u003c/h3\u003e\u003ch2\u003ePhysical symptoms\u003c/h2\u003e\u003cp\u003ePhysical symptoms were assessed via the Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire for Lung Cancer Module (QOL-LC13) [21 22], which comprises 13 items designed to assess 9 physical symptoms associated with lung cancer or its treatment, such as coughing, dyspnea, and chest pain. In this study, patients rated the severity of symptoms experienced in the past week on a scale ranging from (1) \u003cem\u003enot at all\u003c/em\u003e to (4) \u003cem\u003every much.\u003c/em\u003e Because item 13 assesses pain relief with painkillers, the total score of the initial 12 items was used to assess the severity of physical symptoms, with higher scores indicating greater symptom severity. The internal reliability of the 12-item scale is 0.72 in this study.\u003c/p\u003e\u003ch3\u003eIllness perceptions\u003c/h3\u003e\u003cp\u003eIllness perceptions were evaluated using the Brief Illness Perception Questionnaire (BIPQ) [23 24]. This questionnaire consists of 9 items, with each item representing an independent subscale designed to evaluate patients' perception across various dimensions of their illness. In this study, the scoring for the four illness perception dimensions we utilized is as follows: 1) Illness consequences (How much does your illness affect your life?) ranging from (0) \u003cem\u003eno affect at all\u003c/em\u003e to (10) \u003cem\u003eseverely affects my life;\u003c/em\u003e 2) Illness timeline (How long do you think your illness will continue?) ranging from (0) \u003cem\u003ea very short time\u003c/em\u003e to (10) \u003cem\u003eforever\u003c/em\u003e; 3) Personal control (How much do you feel you can control your illness?) ranging from (0) \u003cem\u003eabsolutely no control\u003c/em\u003e to (10) \u003cem\u003eextreme amount of control\u003c/em\u003e; and 4) Treatment control (How much do you think the treatment you are receiving, such as medication, can help control your illness?) ranging from (0) \u003cem\u003enot at all\u003c/em\u003e to (10) \u003cem\u003eextremely helpful\u003c/em\u003e.\u003c/p\u003e\u003ch2\u003eDepression\u003c/h2\u003e\u003cp\u003eDepression was assessed using the depression subscale of the Chinese version of the Hospital Anxiety and Depression Scale (HADS) [25 26]. The depression subscale comprises 7 items, scored on a 4-point scale. Patients rated the severity of each symptom they experienced over the past week. Regarding the depression subscale, similar to our previous published study [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], the item-total correlation for item 10, “I have lost interest in my appearance” (r = 0.07), was significantly lower than the correlations for the other items in the subscale (ranging from 0.31 to 0.57). Furthermore, removing item 10 increased the internal reliability of the depression subscale from 0.65 to 0.74. Therefore, we decided to exclude item 10 and impute its score with the average score of the remaining 6 items. Based on the results of a previous validation study conducted in Chinese cancer patients [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], a total score of 8 was established as the cutoff point for probable diagnoses of depressive disorders.\u003c/p\u003e\u003ch3\u003eQuality of life\u003c/h3\u003e\u003cp\u003eThe 5-level EQ-5D version (EQ-5D-5L) was used to assess the quality of life [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The EQ-5D descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, each with 5 levels ranging from (1) \u003cem\u003eno problems\u003c/em\u003e to (5) \u003cem\u003eextreme problems\u003c/em\u003e. Health utility values for the patients were calculated based on the Chinese residents' health preference model [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Higher utility values represent better quality of life for patients. In the study, the internal reliability of the scale is 0.68.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using SPSS 26.0. Preliminary analyses included descriptive statistical analyses and correlation analyses among variables of major interest. Pearson correlations were performed to assess the associations between the variables of interest and sample characteristics to identify potential covariates to be controlled for in subsequent analyses.\u003c/p\u003e\u003cp\u003eTo test the moderation of four dimensions of illness perceptions, we conducted four hierarchical multiple regression models, one for each dimension of illness perceptions, separately. In step 1, potential covariates and the main effects of physical symptoms and illness perception were entered. In Step 2, the two-way interaction terms (physical symptoms × illness perception, physical symptoms × gender, illness perception × gender) were entered. In Step 3, we entered the three-way interactions among gender, illness perception, and physical symptoms. All variables were centered before the regression analyses to reduce multicollinearity.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003ePreliminary analyses\u003c/h2\u003e\n \u003cp\u003eDescriptive statistics and bivariate correlations of study variables were reported in Table\u0026nbsp;2. The average severity of physical symptoms was 166.72 (SD\u0026thinsp;=\u0026thinsp;127.66). The average depression score was 3.11 (SD\u0026thinsp;=\u0026thinsp;3.10). In this sample, 9.5% (n\u0026thinsp;=\u0026thinsp;316) of patients were above the threshold for probable depressive disorder. As was shown in Table\u0026nbsp;2, there was a negative correlation between education level and depression (\u0026beta; = -0.13, P\u0026thinsp;=\u0026thinsp;0.018), as well as a negative correlation between age and quality of life (\u0026beta; = -0.12, P\u0026thinsp;=\u0026thinsp;0.046). Therefore, education level and age were included as covariates in subsequent hierarchical regression analyses.\u003c/p\u003e\n \u003cp\u003eTable 2. Descriptive statistics and correlations of study variables\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"126%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1. Physical symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e166.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e127.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2. Illness consequences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e5.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e3.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.26\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3. Illness timeline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e5.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e3.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.21\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.26\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4. Personal control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e5.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e2.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.20\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.20\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5. Treatment control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e7.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e2.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.24\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.31\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e6. Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e3.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e3.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.33\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.25\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.21\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.22\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.22\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e7. Quality of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.49\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.26\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.19\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.17\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.18\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.34\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e8. Age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e61.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e9.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.13\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e-0.13\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e9. Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e-0.12\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e-0.30\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003csup\u003e*\u003c/sup\u003eP\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05, \u003csup\u003e**\u003c/sup\u003eP\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026lt; 0.01\u003c/p\u003e\u0026nbsp;\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eRegression Analyses\u003c/h2\u003e\n \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n \u003ch2\u003eDepression as the outcome variable\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eTwo-way interaction between physical symptoms and illness perceptions.\u003c/strong\u003e Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e presents the results of hierarchical regression analyses with four illness perceptions as moderators. There was a significant physical symptoms \u0026times; illness timeline two-way interaction (\u0026beta;\u0026thinsp;=\u0026thinsp;0.12, P\u0026thinsp;=\u0026thinsp;0.028). As recommended by Aiken and West [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], a simple slope test was conducted to compare the association between physical symptoms and depression at high vs. low rating illness timeline. As shown in Figure. 1a, patients with higher illness timeline perception scores exhibited a stronger correlation between physical symptoms and depression (\u0026beta;\u0026thinsp;=\u0026thinsp;0.42, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to those with lower scores (\u0026beta;\u0026thinsp;=\u0026thinsp;0.18, P\u0026thinsp;=\u0026thinsp;0.029). These results suggested that the effect of physical symptoms on depression was relatively more pronounced in patients perceived with a longer illness timeline.\u003c/p\u003e\n \u003cp\u003eTable 3. Hierarchical regression analyses of physical symptoms, illness perceptions, gender, and their interactions on depression\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"683\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cem\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026Delta;R\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cem\u003edf\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 683px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllness consequences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e298\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e13.36\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.28\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eIllness consequences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.18\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e1.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; illness consequences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eIllness consequences \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e294\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e6.46\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; illness consequences \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.17\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 683px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllness timeline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e11.41\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.30\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eIllness timeline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.14\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e273\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e3.20\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; illness timeline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.12\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eIllness timeline \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; illness timeline \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 683px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonal control\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e282\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e11.91\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.30\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePersonal control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.15\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; personal control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePersonal control\u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; personal control \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 683px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment control\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e290\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e11.83\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.29\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eTreatment control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.14\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e1.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; treatment control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eTreatment control \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e286\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e3.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; treatment control \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003csup\u003e*\u003c/sup\u003eP\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05, \u003csup\u003e**\u003c/sup\u003eP\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026lt; 0.01, \u003csup\u003e***\u003c/sup\u003eP\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eThree-way interaction among physical symptoms, illness perceptions, and gender.\u003c/strong\u003e There was a significant physical symptoms \u0026times; illness consequences \u0026times; gender three-way interaction (\u0026beta;\u0026thinsp;=\u0026thinsp;0.17, P\u0026thinsp;=\u0026thinsp;0.012). Simple slope test in Figure. 1b and Figure. 1c showed that among female patients with low levels of illness consequences perception, physical symptoms were not associated with depression (\u0026beta;= -0.02, P\u0026thinsp;=\u0026thinsp;0.910). Among female patients with high levels of illness consequences perception, physical symptoms were positively associated with depression (\u0026beta;\u0026thinsp;=\u0026thinsp;0.27, P\u0026thinsp;=\u0026thinsp;0.042). In contrast, in male patients, regardless of whether they had high or low scores in illness consequences perception, there was a positive correlation between physical symptoms and depression (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The above results suggested that positive illness consequences perception could buffer the negative effects of physical symptoms on depression, but this buffer effect was only significant for female patients.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eQuality of life as the outcome variable\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eTwo-way interaction between physical symptoms and illness perceptions.\u003c/strong\u003e Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e presents that there is a significant physical symptoms \u0026times; illness timeline two-way interaction (\u0026beta;= -0.13, P\u0026thinsp;=\u0026thinsp;0.010). Simple slope test in Figure. 2a showed that for patients with higher illness timeline perception scores, the correlation between physical symptoms and quality of life (\u0026beta;= -0.61, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was higher than for patients with lower illness timeline perception scores (\u0026beta;= -0.34, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These results suggested that the effect of physical symptoms on quality of life was relatively more salient for patients with a more negative perception of the illness timeline.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eTable 4.\u0026nbsp;Hierarchical regression analyses of physical symptoms, illness perceptions, gender, and their interactions on quality of life\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"693\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cem\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026Delta;R\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003edf\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 693px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllness consequences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e305\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e28.21\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.43\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eIllness consequences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.15\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e302\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; illness consequences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eIllness consequences \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e301\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; illness consequences \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 693px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllness timeline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e281\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e24.26\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.46\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eIllness timeline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; illness timeline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.13\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eIllness timeline \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e277\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; illness timeline \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 693px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonal control\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e25.54\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.46\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePersonal control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; personal control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePersonal control\u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5.30\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; personal control \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.14\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 693px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment control\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e292\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e24.91\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.46\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eTreatment control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.10\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; treatment control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e-0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eTreatment control \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eStep 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e288\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5.79\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePhysical symptoms \u0026times; treatment control \u0026times; gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.17\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003csup\u003e*\u003c/sup\u003eP\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05, \u003csup\u003e**\u003c/sup\u003eP\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026lt; 0.01, \u003csup\u003e***\u003c/sup\u003eP\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001\u003c/p\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eThree-way interaction among physical symptoms, illness perceptions, and gender.\u003c/strong\u003e Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e presents that physical symptoms \u0026times; personal control \u0026times; gender interaction (\u0026beta;\u0026thinsp;=\u0026thinsp;0.14, P\u0026thinsp;=\u0026thinsp;0.022) and physical symptoms \u0026times; treatment control \u0026times; gender interaction (\u0026beta;\u0026thinsp;=\u0026thinsp;0.17, P\u0026thinsp;=\u0026thinsp;0.017) are significant. Simple slope tests for significant physical symptoms \u0026times; personal control \u0026times; gender three-way interaction in Figure. 2b and Figure. 2c showed that, among female patients, physical symptoms were not significantly correlated with quality of life for those with higher perceived personal control scores (\u0026beta;= -0.20, P\u0026thinsp;=\u0026thinsp;0.149), whereas for those with lower perceived personal control scores, physical symptoms were negatively correlated with quality of life (\u0026beta;= -0.86, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, among male patients, physical symptoms were negatively correlated with quality of life regardless of perceived personal control scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Simple slope tests for significant physical symptoms \u0026times; treatment control \u0026times; gender three-way interaction in Figure. 2d and Figure. 2e showed that, among female patients, the correlation between physical symptoms and quality of life was higher (\u0026beta;= -0.97, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) for those with lower perceived treatment control scores than for those with higher perceived treatment control scores (\u0026beta;= -0.33, P\u0026thinsp;=\u0026thinsp;0.005). In contrast, among male patients, physical symptoms were negatively associated with quality of life regardless of high or low perceived treatment control scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003cp\u003eThe above results suggested that the buffering effect of positive illness perception (i.e., perceptions of personal control and treatment control of illness) was more salient for female patients.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study takes the first step in investigating the moderating role of illness perceptions on the association of physical symptoms with depression and quality of life in patients with lung cancer. We also examined the gender differences in this moderating effect. Our findings are generally in line with the hypotheses. We found that a positive perception of the illness timeline buffered the negative impact of physical symptoms on depression and quality of life. Moreover, the buffering effects of the perception of illness consequences, personal control, and treatment control were significant only in female patients.\u003c/p\u003e \u003cp\u003eHaving more positive perceptions of the illness timeline (i.e., perceiving the illness timeline as short) helps alleviate the negative impact of physical symptoms on depression and quality of life. Patients with positive perceptions of their illness tend to perceive the illness as temporary, controllable, and having a minimal impact on their lives, with effective treatment options. Recent research has uncovered a positive association between positive illness perceptions and milder depression, along with an improved quality of life [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. These patients with positive perceptions tend to view the burden of symptoms as a relatively minor threat to their overall well-being [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This diminished perceived threat instills confidence in patients, enabling them to take effective measures in coping with their illness, thus mitigating the negative impact of physical symptoms on their emotional well-being and quality of life. In contrast, holding a negative attitude toward the illness may lead patients to be more sensitive to bodily discomfort, potentially escalating into a catastrophic perception of physical symptoms, thereby exacerbating depression and reducing the quality of life [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. It is also plausible that individuals with a positive illness perception are more inclined to seek assistance from medical professionals when faced with symptoms [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Support from healthcare providers and other social support networks can enhance patients' confidence in managing the illness, allowing for a more effective handling of physical symptoms.\u003c/p\u003e \u003cp\u003eMoreover, we found that the buffering effect of illness perception was only significant among female patients. One potential explanation may be related to gender differences in stress coping. Research has indicated that female cancer patients are more inclined to seek support from social networks [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Besides, female cancer patients show greater emotional expressivity than male patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Emotionally expressive coping has also been linked to improved psychological adjustment and physical health among breast cancer patients [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Through seeking support and expressing emotions with social partners, female patients likely have more opportunities to reappraise their disease from a more positive perspective. Consequently, the buffering effect of positive illness perceptions may be more pronounced among female patients. More studies are needed to confirm this finding.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eImplication\u003c/h2\u003e \u003cp\u003eOur findings have implications for the development of interventions for managing symptoms and improving psychological adjustment of lung cancer patients. The results indicate that facilitating positive illness perceptions may be beneficial for reducing the negative impact of physical symptoms on depression and quality of life, especially for female patients. Thus, future interventions on lung cancer symptom management should incorporate a psychoeducation component on how to develop positive illness perceptions. Moreover, given the finding that the buffering effect of illness perception is more salient among female patients, the design of the psychoeducation should also be tailored to the psychosocial needs of female patients. For example, nurses providing patients with health education about the disease and personalized emotional support can improve symptoms, self-management, and quality of life [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Mindfulness-based cognitive therapy aims to promote positive illness perceptions and beliefs that can reduce the level of negative illness perceptions, and improve psychological distress and quality of life [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe present study has several limitations. First, the study used a cross-sectional design, which resulted in correlational findings, making it impossible to conclude the association between physical symptoms, depression, and quality of life. Subsequent longitudinal studies are needed for further validation. Second, there is the reason for caution over the findings\u0026rsquo; generalizability to other patient stages, given that the bulk of the study\u0026rsquo;s patients are in Stage Ⅲ \u0026amp; Ⅳ. Further studies with a wider range of phases are necessary to confirm and extrapolate the results for different stages of the disease. Third, although the study was carried out in a renowned hospital that saw patients from all across the nation, the sample\u0026rsquo;s representativeness is limited because the study was conducted at a single center. Future multi-center studies that include a more diverse patient population may improve the external validity of the results.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, our study has demonstrated that facilitating positive illness perceptions can alleviate the negative impact of physical symptoms on depression and quality of life. Moreover, we found this moderating effect of illness perception was more salient in female patients. Future psychological interventions could target patients' illness perceptions in a personalized manner, employing positive psychological and behavioral strategies to help patients better cope with the effects of the disease.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the ethics committee at the School of Public Health at Shanghai Jiao Tong University School of Medicine (SJUPN-201915). All participants signed informed consent.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eThe findings described in this document have not been previously published, and none of the authors are currently submitting them to another publisher for consideration.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e This study was supported by the National Natural Science Foundation of China [grant numbers: 72004133, 71874111]; and The China Medical Board Open Competition Grants Program [grant number: 22\u0026ndash;479].\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eQiao Chu and Yaping He conceived and designed the study. Danni Dong, Gan He, and Zhenghao Ge collected the data. Zhonglin Chen, Chenyan Han, and Yi Zhao managed the project. Jinhuan Yang conducted the statistical analysis and modeling and drafted the manuscript. Qiao Chu guided the study and oversaw manuscript evaluation and revision.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors acknowledge the assistance of the staff in the Shanghai Chest Hospital in conducting the survey.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe data are not publicly available due to this data containing information that could compromise the privacy of research participants. The data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A et al. 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Cancer. 2018;124(17):3609\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsai K, Hatamochi C, Minamimura F. Association Between Illness Perception and Care-Seeking Intention in Patients With Chronic Heart Failure. Clin Nurs Res. 2023;32(3):669\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStanton AL, Danoff-Burg S, Cameron CL, Bishop M, Collins CA, Kirk SB, et al. Emotionally expressive coping predicts psychological and physical adjustment to breast cancer. J Consult Clin Psychol. 2000;68(5):875\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeldam SWM, Schuurmans MJ, Zanen P, Heijmans MJWM, Sachs APE, Lammers J-WJ. The effectiveness of a nurse-led illness perception intervention in COPD patients: a cluster randomised trial in primary care. ERJ Open Res. 2017;3(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDalili Z, Bayazi MH. The effectiveness of Mindfulness-Based Cognitive Therapy on the illness perception and Psychological Symptoms in patients with Rheumatoid Arthritis. Complement Ther Clin Pract. 2019;34:139\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"health-and-quality-of-life-outcomes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hqlo","sideBox":"Learn more about [Health and Quality of Life Outcomes](http://hqlo.biomedcentral.com)","snPcode":"12955","submissionUrl":"https://submission.nature.com/new-submission/12955/3","title":"Health and Quality of Life Outcomes","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lung cancer, Physical symptoms, Depression, Quality of life, Illness perceptions","lastPublishedDoi":"10.21203/rs.3.rs-6265259/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6265259/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePhysical symptoms negatively affect lung cancer patients\u0026rsquo; emotional well-being and quality of life. It remains understudied about what psychosocial factors may buffer the negative impact of physical symptoms. This study examines how illness perceptions moderate the impact of physical symptoms on depression and quality of life, and further considers gender differences.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a cross-sectional study. 316 lung cancer patients completed questionnaires measuring physical symptoms, depression, quality of life, and illness perceptions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eHierarchical regression analyses reveal significant two-way interactions between physical symptoms and perception of illness timeline on both depression and quality of life. Furthermore, we found significant three-way interactions among physical symptoms, illness perceptions, and gender. Simple slope analyses indicated that positive illness perceptions alleviated the negative effects of physical symptoms on depression and quality of life, particularly in females.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eTherefore, it is essential to tailor the intervention to address the distinct psychosocial needs of male and female patients to enhance the intervention's effectiveness.\u003c/p\u003e","manuscriptTitle":"The Impact of Physical Symptoms on Depression and Quality of Life in Patients with Lung Cancer: The Moderating Effects of Illness Perceptions and Gender","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 05:28:46","doi":"10.21203/rs.3.rs-6265259/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-29T13:46:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-24T04:48:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-09T08:01:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75089964080681837547685766877188284453","date":"2025-04-08T12:21:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187059636461962450945391493622912564948","date":"2025-04-05T05:42:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-03T04:32:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-24T01:53:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T01:50:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"Health and Quality of Life Outcomes","date":"2025-03-20T01:44:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"health-and-quality-of-life-outcomes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hqlo","sideBox":"Learn more about [Health and Quality of Life Outcomes](http://hqlo.biomedcentral.com)","snPcode":"12955","submissionUrl":"https://submission.nature.com/new-submission/12955/3","title":"Health and Quality of Life Outcomes","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d2708e19-dc0f-4961-92b2-a45c748fc43f","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-30T15:59:53+00:00","versionOfRecord":{"articleIdentity":"rs-6265259","link":"https://doi.org/10.1186/s12955-025-02395-7","journal":{"identity":"health-and-quality-of-life-outcomes","isVorOnly":false,"title":"Health and Quality of Life Outcomes"},"publishedOn":"2025-06-23 15:57:22","publishedOnDateReadable":"June 23rd, 2025"},"versionCreatedAt":"2025-05-07 05:28:46","video":"","vorDoi":"10.1186/s12955-025-02395-7","vorDoiUrl":"https://doi.org/10.1186/s12955-025-02395-7","workflowStages":[]},"version":"v1","identity":"rs-6265259","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6265259","identity":"rs-6265259","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}