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Received: 10 February 2020    Revised: 18 August 2020    Accepted: 28 September 2020

DOI: 10.1111/jan.14610

ORIGINAL RESEARCH:
E M P I R I C A L R E S E A R C H - Q U A N T I TAT I V E

Psychological distress and self-management behaviours among

patients with chronic hepatitis B receiving oral antiviral therapy

Ling-Na Kong1,2  | Yu Yao3 | Lin Li4 | Qing-Hua Zhao5  | Tian Wang6 | Yi-Lan Li6

1
School of Nursing, The First Affiliated
Hospital of Chongqing Medical University, Abstract
Chongqing, PR China Aims: To assess the prevalence and associated factors of psychological distress
2
School of Nursing, Chongqing Medical
among patients with chronic hepatitis B receiving oral antiviral therapy and explore
University, Chongqing, PR China
3
School of Nursing, Chongqing Medical and
the association between psychological distress and self-management behaviours
Pharmaceutical College, Chongqing, PR among this population.
China
4
Design: A cross-sectional study.
Department of liver disease, Chongqing
Hospital of Traditional Chinese Medicine, Methods: A convenience sample of 188 patients with chronic hepatitis B receiving
Chongqing, PR China oral antiviral therapy was recruited from March-October 2018 to complete a self-re-
5
Department of Nursing, The First Affiliated
port questionnaire including the Chinese version of Depression Anxiety Stress Scale-
Hospital of Chongqing Medical University,
Chongqing, PR China 21 and Chronic Hepatitis B Self-Management Scale. Logistic regression analysis and
6
Department of infectious disease, The First hierarchical multiple regression analysis were used to determine the factors associ-
Affiliated Hospital of Chongqing Medical
University, Chongqing, PR China ated with psychological distress and the association between psychological distress
and self-management behaviours respectively.
Correspondence
Ling-Na Kong, School of Nursing, The First Results: The prevalence of depression, anxiety, and stress symptoms were 33.0%,
Affiliated Hospital of Chongqing Medical 38.3% and 17.6% respectively. Depression was associated with older age, female
University, Chongqing 400016, PR China.
Email: konglingna926@126.com gender, lower education level and longer treatment duration; anxiety was associ-
ated with female gender and longer treatment duration; and stress was associated
Qing-Hua Zhao, Department of Nursing,
The First Affiliated Hospital of Chongqing with age of 31–40  years, female gender and unmarried status. There were signifi-
Medical University, Chongqing 400016, PR
cant associations between depression and anxiety symptoms and self-management
China.
Email: qh20063@163.com behaviours.
Conclusion: Psychological distress was prevalent among patients with chronic hepa-
Funding information
First Affiliated Hospital of Chongqing titis B receiving oral antiviral therapy and had a negative impact on self-management.
Medical University, Grant/Award Number:
Interventions targeting depression and anxiety symptoms may be beneficial to im-
PYJJ2018-22; 13th Five-year Key Subjects
(Nursing) of Chongqing Education prove self-management behaviours for this population.
Commission
Impact: This study explored the factors associated with psychological distress in pa-
tients with chronic hepatitis B receiving oral antiviral therapy. The findings showed
psychological distress was more common in patients who were with older age, female,
less educated, unmarried and receiving longer duration of treatment and psychologi-
cal distress was significantly associated with self-management behaviours. Nurses
and other healthcare providers should provide interventions to reduce the risk of
psychological distress and improve self-management behaviours for this population.

J Adv Nurs. 2020;00:1–9. wileyonlinelibrary.com/journal/jan© 2020 John Wiley & Sons Ltd     1 |
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2       KONG et al.
KEYWORDS
antiviral therapy, anxiety, chronic hepatitis B, depression, nursing, psychological distress, self-
care, self-management behaviours, stress
1 |  I NTRO D U C TI O N
Chronic hepatitis B (CHB) affected approximately 240 million peo-
ple worldwide and accounted for an estimated 650,000 deaths
each year (World Health Organization,  2015). Patients with
CHB are at a considerable risk of developing severe complica-
tions, including cirrhosis and hepatocellular carcinoma (Terrault
et al., 2016). CHB imposes substantial physical and psychological
burden on patients.
1.1 | Background
Chronic hepatitis B can hardly be cured. Oral antiviral therapy can
prevent the development of CHB-related complications, but not
all patients require treatment. Indications for treatment depend
on the activity and severity of liver disease (Terrault et al., 2016).
The current treatments are unable to completely eradicate the
hepatitis virus. Therefore, most patients require long-term ther-
apy, possibly for life (Dolman et al., 2018). Long-term oral antiviral
therapy may bring psychological burden on patients with CHB.
Long-term antiviral therapy usually imposes a heavy economic
burden on patients, especially for those with poor economic con-
ditions. Patients may also suffer from mental pressure owing to
the higher degree of concern about the unpredictable duration
of oral antiviral therapy and the effects of antiviral therapy on
controlling the disease progression. Although antiviral drugs are
generally safe and well-tolerated by patients, patients are still con-
cerned about the potential side effects (Xu & Liu, 2018). Moreover,
misunderstandings of the infectivity of CHB and discrimination in
society may decrease the patients' social activities (Modabbernia
et al., 2013). The feelings of loneliness and isolation may increase
the psychological pressure on patients.
Like patients with other chronic diseases (Katon, 2011), patients
with CHB often experience different degrees of psychological dis-
tress, such as depression and anxiety. It was reported that the prev-
alence of depressive symptoms in patients with CHB varied from
16–40.6% (Chan et  al.,  2012; Keskin et  al.,  2013; Zhu et  al.,  2016)
and that of anxiety symptoms from 6.7–48.7% (Chan et al., 2012; Vu
et al., 2019; Yilmaz et al., 2016) based on different measurements.
Psychological distress accompanying chronic disease, especially
depression, has an adverse impact on the treatment and prognosis
of chronic disease. An increasing evidence has shown that elevated
psychological symptoms, including depression, anxiety, and stress
have been found to be associated with declined quality of life, poorer
medication adherence, adverse health outcomes and mortality in pa-
tients with chronic diseases and interventions were suggested to be
developed to reduce psychological symptoms (Bujang et  al.,  2015;
Hoogendoorn et al., 2019; Lesman-Leegte et al., 2009; von Leupoldt
et al., 2011).
Self-management is important to control chronic disease.
Complex self-management task is challenging for patients with
chronic diseases and many factors may affect their self-management
behaviours. Previous studies have assessed whether psychological
distress has an impact on self-management behaviours and findings
remain inconsistent. Some studies found psychological distress was
associated with lower level of self-management practices in patients
with diabetes, heart failure and chronic obstructive pulmonary dis-
ease (Devarajooh & Chinna, 2017; Muller-Tasch et al., 2018; Yildirim
et al., 2013), while others found there was nonsignificant association
between psychological distress and self-management (Chlebowy
et al., 2019; Hu et al., 2015).
Patients with CHB should also involve in the daily self-manage-
ment activities to control the disease, including medications, mon-
itoring symptoms, dietary changes and coping with psychosocial
issues (Kong et al., 2015). Self-management has been demonstrated
to have positive effects on medication adherence, clinical outcomes
and quality of life for people with chronic conditions (Grady &
Gough, 2014). Despite the importance of self-management, patient
with CHB showed insufficient self-management behaviours, such as
low adherence to antiviral drugs and abstaining from alcohol (Kong
et al., 2019; Lin et al., 2015). Some factors were found to influence
self-management behaviours in patients with CHB, such as self-ef-
ficacy, social support, family roles, and cultural beliefs about health
care (Kong et  al.,  2019; Lin & Lee,  2019). However, little is known
about the effect of psychological distress on self-management ac-
tivities among patients with CHB.
Given the negative effects of psychological distress on health
outcomes, it is important to explore the prevalence of psychological
distress and which factors contribute to the development of psy-
chological distress among patients with CHB receiving oral antiviral
therapy. However, few studies focus on the psychological distress
among this population and the influence of psychological distress
on self-management behaviours has never been thoroughly inves-
tigated for this population. Therefore, this study aimed to fill this
research gap by examining a group of Chinese patients with CHB.
Based on the literature review, it is hypothesized that psychologi-
cal distress, including depression, anxiety, and stress has negative
effects on self-management behaviours among this population. The
significance of this study lies in the contribution to the understand-
ing of prevalence and related factors of psychological distress and
relationship between psychological distress and self-management
behaviours in patients with CHB receiving oral antiviral therapy
and in offering suggestions for healthcare providers to develop in-
terventions to reduce the risk of psychological distress and improve
self-management behaviours for this population.
KONG et al.
2 | TH E S T U DY
2.1 | Aims
This study aimed to assess the prevalence of psychological distress
among patients with CHB receiving oral antiviral therapy, explore
factors associated with psychological distress and examine the as-
sociation between psychological distress and self-management
behaviours.
2.2 | Design
This study was a descriptive, cross-sectional design. The study fol-
lowed the STROBE checklist for cross-sectional studies.
2.3 | Participants
Using convenience sampling, participants were recruited in two
hospitals in Chongqing, China. Inclusion criteria were as follows:
diagnosed with CHB according to the guidelines and recommen-
dations of the Asian Pacific Association for the Study of the Liver
(Sarin et al., 2014), age of 18 years or older, receiving oral antiviral
treatment at least one month and willing to participate the survey.
We excluded patients if they were co-infected with other viral
hepatitis virus, or human immunodeficiency virus, or with demen-
tia, communication difficulties or other severe health conditions
that may affect them to complete questionnaires. A priori calcula-
tion of sample size (G*Power 3.1.7 software) showed that the min-
imum sample size was 147 with a medium effect size (f 2 = 0.15), an
α value of 0.05, a statistic power (1 − β) of 0.90 and 11 predictive
variables (Cohen, 1988).
2.4 | Data collection
Data were collected from March–October 2018 using a self-report
structured questionnaire. Trained investigators recruited the par-
ticipants at the clinic according to the inclusion criteria. Eligible
participants who agreed to participate in the survey were invited to
complete the paper-and-pencil questionnaire. Investigators distrib-
uted the questionnaires by a one-to-one approach and withdrew the
completed questionnaires on the spot.
2.5 | Instruments
The questionnaire consisted of three sections: demographic and
clinical characteristics list, Depression Anxiety Stress Scale-
21, and Chronic Hepatitis B Self-Management Scale. The de-
mographic data included gender (male and female), age (years),
education level (primary school or below, middle or high school,
|
      3
and college or university), marital status (married and single or
divorced or other), and income (≤2,000, 2,001–3,000, 3,001–
4,000 and >4,000  yuan/month). The clinical data included dis-
ease duration (<5, 5–10 and >10  years), duration of treatment
(1–12, 13–36, and >36 months) and family history with CHB (no
and yes).
Psychological distress was measured by Depression Anxiety
Stress Scale-21 (DASS-21; Lovibond & Lovibond, 1995). It includes
21 items, seven items for each subscale of depression, anxiety, and
stress. Each item was rated by a 4-point Likert scale scoring from
0 (did not apply to me at all)–3 (applied to me very much). The
score of each subscale was calculated by summing the scores for
the relevant items and then multiplied by two. The score for each
subscale ranges from 0–42. Scores in the abnormal range were
Depression > 9, Anxiety > 7, and Stress > 14.
Self-management behaviours were evaluated by the Chronic
Hepatitis B Self-Management Scale (CHBMS; Kong et  al.,  2018). It
comprises of 25 items that cover four domains: symptom (six items),
lifestyle (seven items), psychosocial coping (six items), and disease
information (six items). Items were rated by a 5-point Likert scale
(1 = never do to 3 = neutral to 5 = always do). The total score ranges
from 25–125, with higher scores indicating better engagement in
self-management activities.
2.6 | Ethical considerations
The ethics committee approval was obtained from the First
Affiliated Hospital of Chongqing Medical University (2017170).
This study was performed following the principles of anonymity
and confidentiality.
2.7 | Data analysis
Data analyses were performed using SPSS 20.0 (IBM Corporation).
Descriptive statistics, including frequency, percentage, mean,
and standard deviation (SD), were used to describe the sample
characteristics, depression, anxiety, stress, and self-management
behaviours. Logistic regression analysis was used to determine
the factors (demographic and clinical data) associated with de-
pression, anxiety, and stress symptoms (0 = without depression/
anxiety/stress symptoms, 1  =  with depression/anxiety/stress
symptoms). Factors with a p < .20 in the univariate logistic regres-
sion analysis were included in the multivariate logistic regression
analysis. Crude odds ratios (cORs), adjusted OR (aOR), and their
95% confidence intervals (CI) were reported. Hierarchical multiple
regression analysis was conducted to determine the significance
of depression, anxiety, and stress in relation to self-management
behaviours. For multiple regression analysis, self-management be-
haviour was set as the outcome variable. In the first step, demo-
graphic and clinical data were entered as explanatory variables. In
the second step, depression, anxiety, and stress were entered as
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4       KONG et al.

explanatory variables. p < .05 (two tailed) was considered statisti- TA B L E 1   Sample characteristic and scores of psychological
cally significant. distress and self-management

N (%) Mean (SD)

Age (years) 35.82 (10.10)

2.8 | Validity, reliability, and rigor
≤30 63 (33.5)
31–40 65 (34.6)
Some issues were considered to increase the rigor of this study.
41–50 43 (22.9)
First, the Chinese version of the DASS-21 has been widely used in
various settings and the Cronbach's α and test-retest reliability of ≥51 17 (9.0)

the total scale was 0.91 and 0.75 respectively (Wen et  al.,  2012). Gender

The Cronbach's α of the DASS-21 was 0.91 in the current study. The Male 123 (65.4)
Chinese version of the CHBMS has been also used in people with Female 65 (34.6)
CHB and the Cronbach's α and test-retest reliability of the total score Education
was 0.89 and 0.87 respectively (Kong et al., 2018). The Cronbach's ≤Primary school 13 (6.9)
α of the CHBMS was 0.86 in this study, indicating the acceptable Middle or high school 87 (46.3)
internal consistency reliability. Second, the investigators were well- College or university 88 (46.8)
trained to make sure the data quality. Furthermore, we performed
Marital status
a pilot test among ten patients with CHB. The survey was revised
Married 132 (70.2)
according to their feedback about the ambiguity, errors, and survey
Divorced or other 56 (29.8)
format. Lastly, to ensure the authenticity of the responses, the sur-
Income (yuan/month)
vey was voluntary and anonymous and the participants’ responses
≤2000 28 (14.9)
were ensured to be kept confidential.
2,001–3,000 44 (23.4)
3,001–4,000 51 (27.1)

3 |   R E S U LT S > 4,000 65 (34.6)

Disease duration (years)
3.1 | Participants' characteristics ≤5 59 (31.4)
6–10 51 (27.1)
Among the 200 eligible participants, 12 patients declined to par- >10 78 (41.5)
ticipate due to personal reasons, 188 participants completed the
Duration of current treatment (months)
questionnaire and the response rate was 94.0%. Among them, 123
1–12 74 (39.4)
(65.4%) were male and 132 (70.2%) were married. The mean age was
13–36 67 (35.6)
35.82 (SD 10.10), with the range from 18–66  years old. 41.5% of
>36 47 (25.0)
participants were diagnosed as having CHB for more than 10 years
Family history
and 25.0% were receiving treatment for more than 36  months.
Overall, the prevalence of depression, anxiety, and stress symptoms No 69 (36.7)

were 33.0%, 38.3%, and 17.6%, respectively, indicating psychologi- Yes 119 (63.3)

cal distress was prevalent in patients with CHB. The mean score of Depression
self-management behaviours was 72.91 (SD 13.46), which was ap- Normal 126 (67.0) 3.21 (2.79)
proximately 58.3% of the total scale score, suggesting insufficient Abnormal 62 (33.0) 15.52 (6.06)
self-management behaviours in this population. The participants’ Anxiety
characteristics are listed in Table 1. Normal 116 (61.7) 3.36 (2.15)
Abnormal 72 (38.3) 13.08 (5.96)
Stress
3.2 | Factors associated with psychological distress
Normal 155 (82.4) 7.19 (4.78)
Abnormal 33 (17.6) 22.12 (6.48)
The results of univariate and multivariate logistic regression analysis
Self-management behaviours 72.91 (13.46)
are shown in Tables 2 and 3. Older age (aOR = 4.35, 95% CI: 1.17–
16.22), female gender (aOR = 4.07, 95% CI: 1.92–8.64), lower educa- Abbreviation: SD, standard deviation.
tion level (aOR  =  0.19, 95% CI: 0.04–0.91), and longer duration of
treatment (aOR = 3.49, 95% CI: 1.36–8.93) were risk factors for de- were significantly associated with an increased risk of anxiety symp-
pression symptoms. Female gender (aOR = 2.15, 95% CI: 1.10–4.19) toms. Participants with age between 31–40 years (aOR = 6.68, 95%
and longer duration of treatment (aOR  =  2.29, 95% CI: 1.02–5.15) CI: 2.00–22.33), female gender (aOR = 3.68, 95% CI: 1.53–8.84), and
KONG et al.       5|
TA B L E 2   Factors associated with depression, anxiety, and stress symptoms using univariate analysis

Depression Anxiety Stress

Variables cOR (95% CI) p value cOR (95% CI) p value cOR (95% CI) p value
*
Age (years) .003 .408 .024*
31–40 2.77 (1.21, 6.30) 1.34 (0.65, 2.78) 3.92 (1.45,10.63)
41–50 3.09 (1.27, 7.55) 1.55 (0.69, 3.46) 1.54 (0.46, 5.14)
≥51 6.75 (2.11,21.64) 2.42 (0.81, 7.19) 1.27 (0.23, 6.92)
Gender <.001* .026* .003*
Female 3.72 (1.95, 7.08) 2.01 (1.09, 3.72) 3.22 (1.49, 6.96)
Education .002* .057* .083*
Middle/high school 0.27 (0.08, 0.95) 0.46 (0.14, 1.53) 0.63 (0.17, 2.27)
College and 0.13 (0.04, 0.47) 0.28 (0.08, 0.92) 0.29 (0.07, 1.11)
university
Marital status .235 .070* .193*
Divorced or other 1.49 (0.77, 2.86) 1.80 (0.95, 3.40) 1.69 (0.77, 3.70)
*
Income (yuan/month) .274 .125 .331
2,001–3,000 0.66 (0.25, 1.73) 0.91 (0.35, 2.36) 0.56 (0.18, 1.71)
3,001–4,000 0.53 (0.20, 1.36) 0.54 (0.21, 1.39) 0.54 (0.18, 1.59)
> 4,000 0.41 (0.16, 1.03) 0.41 (0.17, 1.03) 0.35 (0.12, 1.06)
*
Disease duration .031 .636 .430
6–10 years 1.22 (0.51, 2.87) 0.99 (0.45, 2.16) 0.88 (0.30, 2.57)
≥11 years 2.48 (1.17, 5.25) 1.33 (0.66, 2.66) 1.55 (0.64, 3.77)
Treatment duration .001* .021* .046*
13–36 months 2.98 (1.37, 6.46) 1.16 (0.57, 2.34) 1.27 (0.48, 3.34)
>36 months 4.50 (1.96,10.29) 2.74 (1.29, 5.85) 3.06 (1.20, 7.81)
Family history .122* .287 .965
Yes 1.66 (0.86, 3.20) 1.40 (0.75, 2.60) 1.02 (0.47, 2.22)

Abbreviations: CI, confidence intervals; OR, crude odds ratio.

*Included in multivariate logistic regression analysis (p < .20).

unmarried status (aOR = 3.48, 95% CI: 1.25–9.72) were more likely symptoms had a negative impact on patients’ self-management
to suffer from stress symptoms. These findings showed that demo- behaviours.
graphic and clinical characteristics were related to psychological dis-
tress in patients with CHB.
4 | D I S CU S S I O N

3.3 | Association of psychological distress and
self-management behaviours
The results of hierarchical multiple regression analysis for self-
management behaviours are shown in Table  4. In Model 1, self-
management behaviours were significantly associated with
gender (β = 0.18), education level (β = 0.28) and treatment duration
(β  =  −0.23). According to Model 2, self-management behaviours
were negatively associated with depression score (β = −0.30) and
anxiety score (β = −0.29) after demographic and clinical character-
istics were controlled for. Depression and anxiety symptoms ex-
plained the additional 18.4% of the variance in self-management
behaviours. These results suggested that depression and anxiety
In this study, we found depression, anxiety, and stress were prev-
alent in patients with CHB receiving oral antiviral therapy. Age,
gender, education level, marital status, and treatment duration
were identified to influence the prevalence of psychological dis-
tress. Our study also provided evidence that depression and anxi-
ety symptoms were negatively associated with self-management
behaviours.
According to the DASS-21 scores, 33.0%, 38.3%, and 17.6%
of patients with CHB had depression, anxiety, and stress symp-
toms, respectively, in the current study. The prevalence of depres-
sion was similar to the figure reported in Chinese patients with
CHB and cirrhosis (33.3%; Zhu et  al.,  2016), but relatively less
than those reported in other regions, such as 37.5% in Vietnam
 |
6       KONG et al.

TA B L E 3   Factors associated with depression, anxiety, and stress symptoms using multivariate analysis

Depression Anxiety Stress

Variables aOR (95% CI) p value aOR (95% CI) p value aOR (95% CI) p value

Age (years)
31–40 2.50 (0.98, 6.38) .055 6.68 (2.00, 22.33) .002**
41–50 3.11 (1.09, 8.91) .034* 1.71 (0.40, 7.32) .471
*
≥51 4.35 (1.17,16.22) .029 0.75 (0.11, 4.96) .769
Gender
Female 4.07 (1.92, 8.64) <.001** 2.15 (1.10, 4.19) .025* 3.68 (1.53, 8.84) .004**
Education level
Middle/high school 0.30 (0.07, 1.37) .120 0.56 (0.15, 2.02) .372 0.52 (0.12, 2.24) .377
College and university 0.19 (0.04, 0.91) .038* 0.35 (0.09, 1.30) .115 0.21 (0.04, 1.01) .051
Marital status
Divorced or other 2.01 (0.99, 4.05) .051 3.48 (1.25, 9.72) .017*
Income (yuan/month)
2,001–3,000 1.25 (0.44, 3.52) .669
3,001–4,000 0.82 (0.29, 2.29) .702
>4,000 0.58 (0.21, 1.60) .292
Disease duration
6–10 years 0.91 (0.33, 2.51) .861
≥11 years 1.75 (0.71, 4.31) .221
Treatment duration
13–36 months 2.91 (1.17, 7.19) .021* 0.93 (0.43, 1.97) .843 0.86 (0.29, 2.59) .794
** *
>36 months 3.49 (1.36, 8.93) .009 2.29 (1.02, 5.15) .044 2.52 (0.86, 7.37) .092
Family history
Yes 1.51 (0.70, 3.28) .296

Abbreviations: aOR, adjusted odds ratio; CI, confidence intervals.

*
p < .05; **p < .01.

(Vu et  al.,  2019) and 40.6% in Turkey (Keskin et  al.,  2013). The
prevalence of anxiety was lower than that in Turkey (48.7%;
Yilmaz et  al.,  2016), but higher than that in Vietnam (6.7%; Vu
et al., 2019). The discrepancy in the prevalence may be explained
by the difference in participants’ socio-demographic character-
istics, severity level of the illness and instruments for assessing
depression and anxiety. Several possibilities could account for the
high prevalence. First, somatic symptoms related to CHB, such
as fatigue and pain, may increase the risk of psychological dis-
tress. Further, discrimination against people with CHB remains
widespread in China (Huang et al., 2016). Perceived discrimination
and social isolation may be a contributing factor for psychologi-
cal distress. Finally, for patients receiving oral antiviral therapy,
excessive concerns about the consequences and costs of antivi-
ral treatment might impose a heavy burden on patients. Overall,
the high prevalence of psychological distress, especially for de-
pression and anxiety, suggested CHB and its treatment imposed
substantial psychological burden on patients and psychological
care should be provided and strengthened for this population to
decrease the risk of psychological distress.
In our study, some factors were identified to be associated
with psychological distress among patients with CHB receiving
oral antiviral therapy. First, patients of older age had more de-
pression symptoms than younger ones in our study, which was
supported by the previous finding (Vu et  al.,  2019). Second, in
line with a previous study in diabetes (Kaur et  al.,  2013), female
patients were more likely to experience depression, anxiety, and
stress symptoms. Moreover, lower education level was reported
to be a risk factor for depression and stress in our study. Similar
findings were reported in patients with CHB (Vu et al., 2019) and
diabetes (Madkhali et al., 2019). It could be attributed to the fact
that more educated patients can have better access to information
about their health conditions and be more aware and understand
the treatment plan. However, education level was not associated
with depression and anxiety in Keskin et al.'s (2013) study. In addi-
tion, a positive association was found between treatment duration
and depression and anxiety in our study. One possibility would be
that patients suffer from more psychological and financial burden
due to the longer duration of treatment. Inconsistent with previ-
ous study among patients with diabetes (Kaur et  al.,  2013), our
KONG et al. |
      7

TA B L E 4   Hierarchical linear regression analyses for self- between self-management behaviours and psychological distress
management behaviours among patients with type 2 diabetes (Chlebowy et  al.,  2019) and
Model 1 Model 2 patients undergoing haemodialysis (Natashia et al., 2019). Contrary
to our hypothesis, stress was not significantly associated with
Explanatory variables β p value β p value
self-management behaviours, which was supported by Chlebowy
Age −0.02 .796 0.03 .609 et al.'s (2019) study.
Gender 0.18 .007** 0.35 <.001**
Education level 0.28 <.001** 0.17 .006**
Marital status −0.06 .406 0.05 .420 4.1 | Clinical implications
Income 0.11 .114 0.05 .449
Disease duration 0.04 .510 0.11 .078 The present study has some clinical implications for nurses and other

Treatment duration −0.23 .001 **

−0.11 .063
Family history 0.01 .984 0.01 .833
Depression score −0.30 <.001**
Anxiety score −0.29 <.001**
Stress score −0.13 .192
R2 .187 .371
∆R2 .184
Abbreviation: β, standardized coefficients.
*p < .05; **p < .01.
study failed to find the association between disease duration and
psychological distress.
In this study, patients with CHB performed low level of
self-management behaviours. As hypothesized, we observed neg-
ative associations between depression and anxiety symptoms and
self-management behaviours, suggesting those with more symp-
toms of depression and anxiety in general tended to practice worse
self-management behaviours. According to middle-range theory of
self-care of chronic illness, individuals with limited attention and
memory may have little ability to perform self-care activities (Riegel
et al.,  2012). Psychological distress may adversely affect memory,
energy, and executive function, in turn, impair self-management in
patients with chronic conditions (Hu et al., 2015). Moreover, adop-
tion of self-care maintenance behaviours may require motivation
and depressive symptoms can decrease individuals’ motivation to
engage in self-care behaviours (Riegel et al.,  2019). Anxious feel-
ings about consequences of the illness together with uncertainty
regarding treatment effect may also affect their abilities to control
the illness.
Our results were consistent with previous studies, where de-
pression or anxiety symptoms negatively affected self-manage-
ment behaviours among patients with diabetes (Devarajooh &
Chinna,  2017), hypertension (Hu et  al.,  2015), and heart failure
(Muller-Tasch et al., 2018). A review suggested that moderate to se-
vere levels of depression and anxiety may impede patients’ abilities
to engage in self-management behaviours (Fredericks et al., 2012).
Chang et al. (2017) also found a higher level of depressive symptoms
lowered self-care confidence and self-care maintenance among pa-
tients with heart failure. However, conflicting findings were found
in other studies, where nonsignificant associations were found
healthcare providers. First, our study provides information that patients
with CHB face emotional challenges during the oral antiviral therapy,
which necessitates adaptations in healthcare delivery. Interventions
should be provided to improve their psychological health, such as
skills to cope with emotional stressors and knowledge about CHB and
antiviral therapy. Second, regular psychological assessment can help
healthcare providers identify the patients’ mental health status and
test the effects of interventions. Screening for psychological distress
is recommended to be included in health education or management
programs for patients with CHB. In particular, healthcare providers
should be conscientious of those with older age, female gender, lower
education level, and longer duration of treatment, as they may have in-
creased psychological distress. Moreover, our findings could guide the
healthcare providers to better understand the magnitude to which de-
pression and anxiety have an impact on self-management behaviours.
It is important to recognize and address psychological distress when
implementing self-management interventions.
4.2 | Limitations
Some limitations of this study should be noted. First, the cross-sec-
tional design could not demonstrate the causal associations between
risk factors and psychological distress, as well as psychological dis-
tress and self-management behaviours. Longitudinal studies should
be employed to further strengthen the current findings. Second,
participants were recruited from two hospitals using the conveni-
ence sampling method. Thus, selection bias may limit the generaliz-
ability of the findings. Third, self-report questionnaire was used to
collect data, which may possibly introduce recall bias and social de-
sirability bias. Lastly, data on comorbidities were not collected in this
study. This may be an important confounder for predicting psycho-
logical distress and its relationship to self-management behaviours.
5 | CO N C LU S I O N
Psychological distress was common in patients with CHB receiving
oral antiviral therapy and mental health care should be provided
to reduce the risk of psychological distress. Psychological distress
was more prevalent in patients with older age, female gender, lower
education level, unmarried status and receiving longer duration of
 |
8       KONG et al.
treatment. Further, depression and anxiety symptoms were signifi-
cantly associated with self-management behaviours, indicating in-
terventions targeting depression and anxiety symptoms may benefit
to improve self-management behaviours for this population.
AC K N OW L E D G E M E N T S
We are grateful to all participants for their involvement in the survey.
C O N FL I C T O F I N T E R E S T
No conflict of interest has been declared by the author(s).
AU T H O R C O N T R I B U T I O N S
All authors have agreed on the final version and meet at least one of
the following criteria (recommended by the ICMJE*): http://www.
icmje.org/recom​menda​tions/.
1. substantial contributions to conception and design, acquisition
of data, or analysis and interpretation of data;
2. drafting the article or revising it critically for important intellec-
tual content.
ORCID
Ling-Na Kong  https://orcid.org/0000-0003-4612-5389
Qing-Hua Zhao  https://orcid.org/0000-0002-3115-3128
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