The World Health Organization (WHO) has declared the coronavirus disease 2019 (COVID-19) pandemic to be over on May 5, 2023 [1]. While the pandemic may have officially come to an end, it is crucial to reflect on the lessons learned during this challenging period. The lessons learned can help us better prepare for and mitigate the effects of future health crises and strengthen the approaches to safeguarding public health.

During the COVID-19 pandemic, healthcare services for noncommunicable diseases have been significantly impacted [2]. The entire continuum of cancer care, i.e. screening, diagnoses, treatment, and palliative care, has also been severely disrupted in the pandemic [3]. The impacts were particularly devastating in low- and middle-income countries (LMICs), including Indonesia [4, 5].

Maintaining cancer care while mobilizing healthcare resources to manage COVID-19 presented significant hurdles for the LMICs [5]. In normal times, most LMICs have considerable obstacles in terms of the availability, accessibility, and affordability of cancer care services [5]. The majority of healthcare systems experience severe disruption of routine services as they struggle to handle the growing influx of patients with COVID-19 [5]. Patients’ access to the hospital was limited due to strictly enforced confinement rules or mandatory lockdowns. In addition, cancer treatments were delayed or postponed to minimize the risk of cancer patient exposure to COVID-19 [4-6].

The COVID-19 pandemic has also severely affected breast cancer patients [7]. Breast cancer is the most prevalent cancer among women globally as well as in Indonesia, accounting for 11.7% and 19.2% of all cancers, respectively [8, 9]. According to Chinese and Italian studies, 8.3% to 29% of breast cancer patients were infected by COVID-19 [10, 11]. An international registry also reported that, among the cancer patient population, COVID-19 cases mostly occurred in breast cancer patients (21%) [12]. Thus, breast cancer is a particularly significant public health concern during the pandemic.

The management of breast cancer patients has been reorganized by the health care services in the COVID-19 pandemic [7, 13]. Nonurgent surgeries and radiotherapy were delayed, chemotherapy and immunotherapy schedules were spread out, and oral therapies replaced intravenous treatment [13, 14]. According to a patient report, the most frequent delays were in routine or follow-up clinic consultations, diagnostic imaging, and lab testing procedures [15]. Apart from the service delays and changes, breast cancer patients also experienced heightened anxiety, psychological distress, and a sense of isolation along with decreased social support during the pandemic [16].

To cope with those challenges, self-efficacy, and self-management became particularly crucial for breast cancer patients during the pandemic. The pandemic necessitates that cancer patients take on a more active role in self-managing their symptoms and adjusting to the altered healthcare resources, underscoring the critical role that self-efficacy plays in this process [17]. Self-efficacy refers to one's confidence in his/her own ability to carry out a particular behavior [18]. Self-efficacy influences how patients manage their illness and overcome obstacles caused by the disease [19]. It also facilitates the adoption and maintenance of healthy behaviors [19]. Studies also found that self-efficacy predicts self-management [20, 21].

Despite their essential roles, information regarding the self-efficacy and self-management of breast cancer patients during the COVID-19 pandemic is very limited. Therefore, this study aimed to assess: 1) self-efficacy of the breast cancer patients undergoing therapy during the COVID-19 pandemic; 2) self-management of the breast cancer patients undergoing therapy during the COVID-19 pandemic; 3) factors associated with self-management of the breast cancer patients undergoing therapy during the COVID-19 pandemic.

This study provides valuable evidence regarding the self-efficacy and self-management, among other factors including social support and psychological factors, of the breast cancer patients under treatment during the COVID-19 pandemic. In this study, the proportion of breast cancer patients with a high level of self-efficacy was 9.2% higher than that of patients with a low level of self-efficacy. This finding is somewhat similar to a study conducted in Saudi Arabia [33]. However, a study in Turkey found otherwise: the majority of cancer patients undergoing chemotherapy reported having a low level of self-efficacy [34]. Al-Harithy argued that the strong religious faith and the culture of close family ties might contribute to building the self-efficacy of Saudi Arabian cancer patients [33]. This explanation is relevant to the Indonesian context, where most Indonesians are religious and have strong family support.

While the study found that there was a slightly higher percentage of breast cancer patients who had high self-efficacy, it is crucial not to neglect the sizeable population of patients with poor self-efficacy, especially in the context of the COVID-19 pandemic. The pandemic has brought additional challenges and uncertainties for the patients, so they should rely more on their self-efficacy. Recognizing the values of self-efficacy becomes even more important in these circumstances, as it equips the patients with the skills they need to navigate the complexities of the pandemic, make informed decisions about their health, and follow the necessary precautions and treatment regimens. A systematic review has shown that self-efficacy is positively correlated with health-promoting behaviors while being inversely related to physical and psychological symptoms in adolescents and young adults with cancer [35]. Another review of studies in adults with cancer found similar results [17]. Cancer patients with high self-efficacy are also more likely to have better general health and quality of life [17].

A key finding of this study is that self-efficacy is the strongest predictor of self-management among breast cancer patients in the pandemic. This finding is consistent with the results of previous studies assessing patients with chronic diseases, including cancer [33, 36] and diabetes mellitus [37-39]. Self-efficacy has been suggested as a useful framework to explain variance in self-management behaviors [19, 40]. According to Bandura’s theory, self-efficacy is based on four different types of mastery experiences: i.e. enactive experiences, vicarious experiences, verbal persuasion, and physical and emotional states [19]. The representations of illness and its treatments provide a way for the patients to develop these mastery experiences [40]. Cancer patients can build their self-efficacy by actively taking part in their self-management activities, such as following treatment plans and adopting healthy habits. In addition, getting trustworthy verbal persuasion from reputable sources (e.g. healthcare professionals) and controlling one's bodily and mental states can all aid in the development of self-efficacy. In addition, patients’ self-efficacy can further influence their behaviors through cognitive processes (such as future planning) and motivational processes (such as increased commitment to goals), as well as potentially disruptive affective processes (such as fear of failure). Therefore, there could be a reciprocal process of self-efficacy affecting behavioral outcomes and vice versa.

Additionally, this study also found that social support is positively associated with self-management in breast cancer patients. Consistently, an increasing number of studies have provided evidence that social support affects, both directly and indirectly, the self-management of cancer patients [41, 42]. Through interactions with their social circles, patients can be persuaded and reinforced to actively manage their illness. A prior study in breast cancer survivors also found that social support can positively influence communication, coping mechanisms, information-seeking, and healthy behaviors through the path of improving self-efficacy [41]. Moreover, a study in Malaysia during the COVID-19 pandemic showed that social support can enhance learning experiences [43]. Strong social support from the closest circle, such as spouses or family members, might compensate for the reduced access to healthcare services.

In this study, another significant association was found between cancer stage and self-management. Patients with a higher stage of breast cancer were more likely to report better self-management. A previous study also showed that self-management differed by cancer stage [44]. Patients with advanced cancer, for example, commonly have a shorter prognosis with more complex treatment regimens, requiring a wider range of self-management strategies, ranging from medication and lifestyle to psychological management such as managing the end of life [45]. Hence, programs to promote self-management should consider the stage of cancer as well as the needs and abilities of the patients and their caregivers.

On the other hand, this study found no significant relationship between anxiety depression and self-management. This finding was quite surprising since psychological status has been suggested as one of the factors affecting self-efficacy, which might in turn influence self-management. However, in line with this study’s finding, a meta-analysis conducted by Kim and colleagues found that self-management interventions had no statistically significant effects on anxiety and depression in cancer patients who had completed primary treatments [46]. The authors argued that this insignificant finding might be partly attributed to the minimal or mild levels of anxiety and depression among the patients included in the studies [46]. Those studies in Kim’s meta-analysis also did not target anxiety and depression as their primary outcomes. Further studies are needed to provide more evidence regarding how psychological factors may contribute to self-management and how self-management can also improve psychological well-being in cancer patients.

A national program implemented in the Netherlands has shown that improving self-management in patients with chronic illness can provide a significant social return on investment driven as much by the higher quality of life and lower healthcare costs [47]. Among cancer patients, quality of life is a major outcome that can be improved by self-management interventions, as demonstrated by Kim’s meta-analysis [46]. However, a more recent meta-analysis showed that self-management interventions using digital means were only effective for improving self-efficacy and cancer-related fatigue but not quality of life [48]. These various findings may indicate that the link between self-management and well-being is not always straightforward [49]. An increasing body of evidence, nevertheless, has supported the benefits of self-management in patients with chronic diseases, including cancer patients.

Self-management behavior becomes increasingly important for patients with chronic conditions such as breast cancer in the COVID-19 pandemic due to the barriers to accessing healthcare services [50]. In a Dutch longitudinal study conducted before the pandemic in 2018 and during the pandemic in 2020, Menting et al. found that people with chronic diseases experienced varied self-management: improved (15.1%), deteriorated (14.2%), and stable (70%) [50]. Consistent with our study findings, social support was significantly related to changes in self-management behavior. The present study findings reiterate the importance of involving spouses, caregivers, or family members in the interventions to improve the self-management behaviors of cancer patients in times of crisis.

This study has some inherent limitations. The cross-sectional design limits the ability of the study to capture changes in self-efficacy and self-management behaviors of breast cancer patients over time, both prior to and during the pandemic. This study design also does not allow for causal inference between variables. Additionally, we only measured self-efficacy in relation to self-management, taking into account social support and psychological factors. Other potentially influential factors, such as access to healthcare resources, might have been missed. Furthermore, this study was less representative due to the limitations of the convenience sampling method. Future trials with robust designs and a sufficient timeframe for evaluation should be conducted to improve the self-management behaviors of breast cancer patients in Indonesia.

It can be concluded that self-efficacy is strongly and positively associated with self-management in breast cancer patients undergoing treatment. The proportion of breast cancer patients with higher and lower levels of self-efficacy and self-management behavior was almost similar. Other factors associated with self-management were social support and the cancer stage.

The findings of this study highlight some implications for nursing care for breast cancer patients. Firstly, nursing interventions focusing on enhancing patients’ self-efficacy are needed. Nurses should also assess and address the unique needs of patients with lower self-efficacy. Strategies such as providing tailored education, counseling, and support may improve patients’ self-efficacy and self-management behaviors. Nurses should also involve the social support network of the patients, including spouses and family members, in promoting self-management behaviors. Moreover, nurses can also facilitate peer support groups for patients or connect them with community resources.

One of the lessons learned from the COVID-19 pandemic is the need to adopt telehealth or remote care delivery methods, which can decrease some gaps in case access and equity [51]. Consequently, bolstering patients' self-efficacy is becoming more important. Nursing can play a crucial role in this matter by leveraging technology to deliver personalized education and support. In addition, nurses can also foster a sense of community and connection among breast cancer patients through online peer support groups. Nevertheless, to reduce healthcare inequities, telehealth tools should be designed to address patients' needs and consider the digital divide. Attention should be paid to improving the e-health literacy of breast cancer patients to protect them from misinformation and fraud on virtual platforms.

DS carried out the data collection and prepared the first draft of the article. TN conceived and designed the study. DG conducted the analysis and interpretation of the data. AM added the overall interpretation and prepared the final draft of the article. All authors have critically reviewed, revised, and approved the final draft of the paper.