Reliability and Validity Study of a Tool to Measure Cancer Stigma: Patient Version

Quitting smoking after a cancer diagnosis is associated with reductions in stigma and anxiety: A longitudinal mediation analysis

Internalized cancer stigma is high among cancer patients who smoke, but it is unknown whether the experience of stigma changes after quitting smoking post-diagnosis. Using data from an RCT of tobacco treatment, we conducted a secondary data analysis and hypothesized that 1) cancer patients who quit smoking would report greater reductions in internalized cancer stigma, compared to patients who did not quit and that 2) greater reductions in stigma would significantly mediate the relationship between smoking abstinence and subsequent decreases in anxiety and depressive symptoms. Participants (n=303; 56.1% female) were adults recruited from two comprehensive cancer centers who had smoked in the past 30 days, spoke English or Spanish, and were being treated for a recent diagnosis of cancer. Participants completed questionnaires at baseline, 3-month follow-up, and 6-month follow-up, and biochemically verified smoking abstinence was determined by participants' salivary cotinine or carbon monoxide levels. Smoking abstinence at 3-month follow-up was significantly associated with reductions in cancer-related stigma from baseline to 3-month follow-up (b = -1.50, p < .001), controlling for sociodemographic and medical covariates. Additionally, reductions in stigma were associated with reductions in anxiety at 6-month follow-up (b = 0.28, p < .05), but not depressive symptoms. Reductions in stigma significantly mediated the relationship between smoking abstinence and decreased anxiety (indirect effect = -0.42, p < .05), but not depressive symptoms. Smoking cessation may be associated with reduction in internalized cancer stigma. Thus, in addition to benefits for medical outcomes, quitting smoking post-diagnosis may improve psychosocial well-being.

Pathway to care among adolescents and young adults with breast cancer in Nigeria: a mixed methods study

BACKGROUND

The mortality from breast cancer (BC) is still high in Nigeria and other low-and medium-income countries (LMICs) especially among adolescents and young adults. This is partly due to late presentation for diagnosis and treatment. It is recommended that to optimize the effectiveness of treatment, the total time which is the interval from symptom onset to initiation of treatment, should be less than 90 days as recommended by the World Health Organization (WHO). The aim of this study was to determine the extent of delays in accessing care and possible reasons for such delays among young adult females with breast cancer in Nigeria.

METHODS

A mixed-method convergent parallel study design was used. The study was conducted at two academic hospitals in southwest Nigeria. Data were collected using a semi-structured assessment tool and an in-depth interview guide. Both the quantitative and qualitative data were collected concurrently. This approach was adopted to aid in the collection of different but complimentary data at the study sites to enrich the interpretation of the results.

RESULTS

A total of 46 female participants were recruited into the quantitative component of the study, and the mean age was 34.2 ± 4.4 years. Most had higher education, were married, and were in a lower earning bracket. Majority participants had low knowledge of symptoms and signs of breast cancer. As low as 7 (15.2%) patients had the time between symptom discovery and treatment initiation [Total Treatment Time (TT)] within 90 days (median 281.5; range 31-5260). Twenty-seven (58.6%) participants had diagnostic interval within 60 days (median 40 days [Inter Quartile Range (IQR) 7-4745 days]. Most participants interviewed 39 (85%) knew that breast lump was a possible sign of breast cancer while a sizable number 19 (41%) could not name risk factors for breast cancer. Family history was the most recognised risk factor for breast cancer by 21(46%) of participants interviewed.

CONCLUSION

Breast health awareness is low among adolescents and young adults with breast cancer in Nigeria, as most participants 33(72%) lacked knowledge of early symptoms and signs of breast cancer. Very few 7(15%) of the participants commenced treatment within the WHO recommended 90 days of noticing breast symptoms. Sixty percent of the participants met the diagnostic interval of within 60 days as against recommended 80%. There is need to intensify the education of young Nigerian females on breast cancer and the importance of breast self-examination.

Feasibility, acceptability, and initial efficacy of empathic communication skills training to reduce lung cancer stigma in Nigeria: a pilot study

Effective communication about cancer diagnosis and prognosis in sub-Saharan African oncology settings is often challenged by the cancer-related shame and stigma patients and families experience. Enhancing empathic communication between health care providers, including physicians and nurses, and oncology patients and their families can not only reduce cancer stigma but also improve patient engagement, treatment satisfaction, and quality of life. To reduce lung cancer stigma, we adapted an evidence-based empathic communication skills training intervention to reduce patients' experience of stigma in Nigeria and conducted a pilot study examining the feasibility and acceptability of the empathic communication skills training. Thirty health care providers, recruited from University College Hospital, Ibadan, and Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, participated in a 2.25-hour didactic and experiential training session. Participant surveys were completed before and after the training. Overall, participants reported highly favorable training evaluations, with at least 85% of health care providers agreeing or strongly agreeing to survey items assessing training relevance, novelty, clarity, and facilitator effectiveness. Self-efficacy to communicate empathically with patients increased significantly from before-training (Mean [SD] = 3.93 [0.28]) to after-training (Mean [SD] = 4.55 [0.15]; t29 = 3.51, P < .05). Significant improvements were observed in health care provider reports of empathy toward lung cancer survivors and attitude toward lung cancer care as well as significant reductions in lung cancer blame were noted. The empathic communication skills training was feasible, well received by oncology clinicians in Nigeria, and demonstrated improvements in health care provider-reported outcomes from before- to after-training.

Psychometric Characteristics of the Chinese Version of the Tuberculosis Related-Stigma Scale in a Population of Medical Students and Its Correlation with Selected Demographic Characteristics

Background

As future health workers, medical students' attitudes towards tuberculosis (TB) patients can impact TB control. However, in China, there is a lack of well-quantified assessment regarding the stigma among medical students towards TB patients. Therefore, this study aimed to validate the Chinese version of the Tuberculosis related-Stigma Scale (TSS) in medical students and to apply the scale to measure stigma and its determinants.

Methods

A total of 1035 eligible medical students participated in the cross-sectional questionnaire. Exploratory factor analyses (EFA) and confirmatory factor analyses (CFA) were first conducted to test Chinese version of the TSS construct validity, and then internal consistency was assessed using Cronbach's α. Finally, multiple linear regression analyses were conducted to identify predictors of stigma.

Results

EFA extracted two factors ("Social distance" and "Exclusionary sentiments"). The CFA further confirmed the two-factor construct. The internal consistency, convergent and divergent validity of the adapted Chinese version of the TSS was acceptable. Furthermore, Whether one has received TB health education and whether know a person with TB are associated with all dimensions of TB stigma, while differences in sex and place of residence play different roles in influencing the different dimensions of stigma.

Conclusion

The adapted Chinese version of the TSS can be used to assess the level of stigma among medical students in China towards tuberculosis patients. When implementing future interventions to reduce stigma associated with TB, special attention should be given to medical students from urban areas, of male gender, who have not received TB health education, and no know a person with TB. However, these two dimensions ("Social distance" and "Exclusionary sentiments") are impacted by different determinants and should therefore be addressed separately when designing, implementing, and evaluating measures to reduce stigma.

Assessment tools for stigma in breast cancer patients based on COSMIN guidelines: a systematic review

OBJECTIVE

The objective of this study was to conduct a systematic review of the measurement properties and methodological quality of stigma assessment tools designed for breast cancer patients. The aim was to provide clinical medical staff with a foundation for selecting high-quality assessment tools.

METHODS

A comprehensive computer search was carried out across various databases, including SinoMed, China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science and Technology Journal Database(VIP), Embase, PubMed, Web of Science, The Cochrane Library, and Scopus, which were searched from the inception of the databases until March 20, 2023. Literature screening and data extraction were performed independently by two researchers, adhering to predefined inclusion and exclusion criteria. The assessment tools were evaluated using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) systematic evaluation guidelines.

RESULTS

In the final analysis, a total of 9 assessment tools were included. However, none of these tools addressed measurement error, cross-cultural validity, criterion validity, and responsiveness. Following the COSMIN guidelines, BCSS and CSPDS were assigned to Class A recommendations, while the remaining tools received Class B recommendations.

CONCLUSION

The BCSS and CSPDS scales demonstrated comprehensive assessment in terms of their measurement characteristics, exhibiting good methodological quality, measurement attribute quality, and supporting evidence. Therefore, it is recommended to utilize these scales for evaluating breast cancer stigma. However, further validation is required for the remaining assessment tools.

Culturally-informed adaptation and psychometric properties of the Cataldo Cancer Stigma Scale in Northern Tanzania

BACKGROUND

Cancer-related stigma impacts patients' emotional health, care engagement, and cancer outcomes, but few measures of cancer stigma exist. We culturally adapted and assessed psychometric properties of the Cataldo Cancer Stigma Scale (CCSS) in Tanzania.

METHODS

We administered the CCSS short version (21 items), plus 12 locally-derived items, to 146 adult cancer patients. We conducted exploratory factor analysis, examined internal consistency/reliability, and assessed convergent validity with relevant measures.

RESULTS

We identified a 17-item cancer stigma scale with strong psychometric properties and four subscales: enacted stigma, shame and blame, internalized stigma, and disclosure concerns. Stigma was rare except for disclosure concerns. Stigma was positively associated with depression and anxiety and negatively associated with social support, quality of life, and illness acceptance.

CONCLUSIONS

The scale provides valid, culturally-informed measurement of cancer stigma in Tanzania. Future studies should assess associations with care engagement, which will inform interventions to reduce stigma and improve outcomes.

Development and Validation of Social-Cognitive Theory Based Oral Cancer Awareness Assessment Tool for Adolescents

Introduction

Creating oral cancer awareness among adolescents will bring change by modifying the risk factors responsible for oral cancer. Social cognitive theory (SCT) is one promising theory for developing oral cancer awareness programmes among school adolescents. However, data are limited on SCT-based intervention assessment in creating oral cancer awareness among rural community. To develop and validate a SCT-based Oral Cancer Awareness (SCT-OCA) assessment/survey tool for evaluation of intervention implementation.

Material and Methods

A mixed method design encompassing both qualitative and quantitative was accomplished to develop and validate the assessment tool for rural setting.

Methods and Material

Domains and items for SCT-OCA assessment tool for adolescents were selected using subject matter expert. A 21-item assessment tool was developed using three rounds of Delphi technique and validated using Lawshe method. The knowledge on oral cancer and its risk factors and key constructs of social-cognitive theory was selected as items of the tool. The final assessment tool was translated to regional language, which was used for evaluation of intervention implementation. Statistical analysis was conducted using SPSS, version 16. Descriptive statistics includes means, standard deviations and frequency. Validation using Lawshe, component factor analysis and Cronbach alpha coefficients were calculated.

Results

The overall content validity ratio was agreeable, and 21 items were finally selected in assessment tool. The overall Cronbach's alphas of 0.718 for survey was acceptable. The agreement was good for the domains of tool.

Conclusions

This study developed the SCT-OCA assessment tool for intervention specifically designed for adolescents to measure oral cancer awareness.

Development & validation of scales to assess stigma related to COVID-19 in India

Background & objectives

COVID-19 pandemic has triggered social stigma towards individuals affected and their families. This study describes the process undertaken for the development and validation of scales to assess stigmatizing attitudes and experiences among COVID-19 and non-COVID-19 participants from the community.

Methods

COVID-19 Stigma Scale and Community COVID-19 Stigma Scale constituting 13 and six items, respectively, were developed based on review of literature and news reports, expert committee evaluation and participants' interviews through telephone for a multicentric study in India. For content validity, 61 (30 COVID-19-recovered and 31 non-COVID-19 participants from the community) were recruited. Test-retest reliability of the scales was assessed among 99 participants (41 COVID-19 recovered and 58 non-COVID-19). Participants were administered the scale at two-time points after a gap of 7-12 days. Cronbach's alpha, overall percentage agreement and kappa statistics were used to assess internal consistency and test-retest reliability.

Results

Items in the scales were relevant and comprehensible. Both the scales had Cronbach's α above 0.6 indicating moderate-to-good internal consistency. Test-retest reliability assessed using kappa statistics indicated that for the COVID-19 Stigma Scale, seven items had a moderate agreement (0.4-0.6). For the Community COVID-19 Stigma Scale, four items had a moderate agreement.

Interpretation & conclusions

Validity and reliability of the two stigma scales indicated that the scales were comprehensible and had moderate internal consistency. These scales could be used to assess COVID-19 stigma and help in the development of appropriate stigma reduction interventions for COVID-19 infected, and mitigation of stigmatizing attitudes in the community.

Determination of the Association between Perceived Stigma and Delay in Help-Seeking Behavior of Women with Breast Cancer

Background:One of the leading causes of death in patients with breast cancer is delays in help-seeking, which is influenced by various factors, including social factors such as cancer stigma. Objectives:This study aimed to determine the relationship between perceived stigma and delay in seeking help for women with breast cancer. Methods:In this cross-sectional study, 140 women with breast cancer referred to Besat Clinic in Rasht, Iran, were included. The data gathering tools included a demographic questionnaire, a cancer stigma questionnaire and a delay questionnaire completed through interviews with patients. Data analysis was performed using SPSS software V.21 and the descriptive and inferential statistics were performed using correlation coefficient, chi-square test, logistic regression, Mann-Whitney U-test, and Kruskal-Wallis test. Results:In this study, 72.1% of patients were aged between 39 and 57 years, with a mean age of 47.99±8.03 years; 34.3% and 16.4% of patients delayed seeking help between 30 and 90 days, and more than 90 days (with mean±SD of 75.35±165.19), respectively. Breast cancer stigma was present in 45% of patients. Delay in seeking help based on stigma was significant (P <0.001). Due to multiple logistic regression, the association between stigma and delayed relief was significant (P <0.01), so that in women suffering from breast cancer with stigma, the chance of delaying seeking help was 5.7 times (OR 5/706, Cl 95% 1.381-23.572) higher than women without stigma. Conclusion:Stigma may be a factor in delaying the screening of women with breast cancer. Therefore, it is recommended that the health care team considers stigma as one of the most important psychological aspects of breast cancer, which may have an impact on patients' delay in seeking help. It should also be considered in the process of diagnosis, treatment counseling, and patient follow-up.

Association between cancer stigma and job loss among cancer survivors

OBJECTIVE

Previous qualitative studies found cancer stigma was associated with work discrimination and job loss among cancer patients. This study aims to quantify the association between cancer stigma and job loss among cancer survivors.

METHODS

For this study, we used the data from a face-to-face cross sectional survey conducted at two cancer hospitals in Seoul and Hwasun in South Korea from October 2017 to March 2018. Cancer stigma was assessed using a validated questionnaire which consists of 12 items in three domains: (a) impossibility of recovery; (b) stereotypes; and (c) discrimination. Multivariable logistic regression was performed to evaluate the association between cancer stigma and job loss adjusting age, sex, marital status, education, job type, residence area, cancer site, stage, comorbidity, time since diagnosis, and self-efficacy.

RESULTS

Among 433 cancer survivors, 24.0% lost their jobs after cancer, and 20.7% experienced discrimination at work. Of total, 21.7% of the survivors agreed that it was difficult to treat cancer regardless of highly developed medical science. Survivors with stigma on impossibility of recovery and stereotypes were 3.10 (95% confidence interval [CI]: [1.76, 5.44]) and 2.10 (95% CI: [1.20, 3.67]) times more likely to lose a job than survivors without cancer stigma. Survivors with discrimination experience at work had 1.98 (95% CI: [1.05, 3.74]) times higher risk of losing a job than survivors without it.

CONCLUSIONS

Survivors with cancer stigma were more likely to lose their jobs than survivors without cancer stigma. Considering its social and economic impact on job loss, comprehensive interventions for working cancer survivors as well as public campaigns against cancer stigma would be necessary.

Stigma and Its Influence on Patients With Temporary Ostomy: A Cross-sectional Survey

PURPOSE

The purpose of this study was to explore stigma and its influencing factors in Chinese patients with a temporary ostomy.

DESIGN

Cross-sectional, descriptive.

SUBJECTS AND SETTING

Convenience sampling was used to recruit 170 patients living with a temporary ostomy for at least 2 weeks. Participants were recruited from 3 general hospitals in Guangdong province, located in southeastern China.

METHODS

Respondents completed a questionnaire that included ostomy-related sociodemographic questionnaire, the Social Impact Scale, and the Stoma Self-Efficacy Scale. Multivariate linear regression was used to identify factors influencing stigma.

RESULTS

Of the 170 questionnaires distributed, 159 (93.5%) respondents who sufficiently completed responses were included in the final analysis. The average score of the Social Impact Scale was 61.63 (SD = 8.39), reflecting a moderate level of stigma, and 27 (17%) experienced high levels of stigma. Multivariate regression analysis revealed that stigma was associated with family relationships (B = 6.139, P = .000), age when ostomy was created (B = -4.038, P = .000), and self-efficacy (B = -0.080, P = .002).

CONCLUSIONS

The level of stigma in Chinese patients with temporary ostomies is moderate. Multivariate regression analysis identified family relationship, age, and self-efficacy as the main factors that influenced stigma in patients with temporary ostomy.

Turkish version of the cancer stigma scale: validity and reliability study

In this study, the Turkish adaptation of the Korean Cancer Stigma Scale (CSS), which was developed by So, Chae, Kim, (2017), was studied for validity and reliability. Modeling of the methodological type of study sample in medicine. Of the cancer patients who came to oncology clinics and ambulatory chemotherapy units for treatment, 327 were included. Data were collected by using a personal information form and the CSS. The translation-retranslation method was used to test the Turkish validity and reliability of the original version of the CSS in English. Six sub-dimensions similar to the original CSS form were identified and factor loads were found between 0.197 and 0.903 as a result of exploratory factor analysis. However, item 6 (0.197) was removed from the scale as its factor load diverged from the recommended value. Kaiser-Meyer-Olkin (KMO) and Bartlett's sphericity tests were used to evaluate the adequacy and suitability of the sample of the research before performing the factor analysis. The KMO value was found to be 0.894, and this value showed that the scale was suitable for factor analysis. Likewise, Bartlett's sphericity test results (x² = 4008.269, p = 0.000) show that the data are suitable for factor analysis. Many indices were used to examine the fit of the model belonging to CSS. Of these, x²/SD value was found to be 2.928, GFI 0.856, IFI 0.905, CFI 0.904, RMSEA 0.077 and SRMR 0.057, and it was decided that the scale was acceptable. The Cronbach alpha coefficient value measured for CSS is equal to 0.897. The Cronbach alpha coefficient for the CSS sub-dimension 'social isolation' is equal to 0.917, 'distancing or avoiding' 0.852, 'attribution' 0.898, 'guilt' 0.758, 'discrimination' 0.692 and 'lack of medical support' 0.664. Confirmatory factor analysis fit index values, normal and acceptable values were determined for CSS consisting of 23 items and 6 sub-dimensions.

Development of the Breast Cancer Stigma Scale for Arab Patients

Objective:

Health-related stigma is associated with depression, but there is a lack of studies examining the stigma of cancer in Arab patients. The purpose of this study was to establish the reliability and validity of a newly developed, culturally sensitive measure of stigma among Arab women with breast cancer.

Methods:

The sample consisted of 59 Arab women with breast cancer who were Muslim, on active oncology treatment. The mean age of women was 49 years (standard deviation = 8.31). Content validity was assessed by calculating a Content Validity Index (CVI) based on ratings from seven oncology experts. Convergent validity was assessed by examining the association with a measure of depressive symptoms. Reliability was assessed by calculating Cronbach's alpha.

Results:

The measure demonstrated strong content validity (item-CVIs ranged from 0.85 to 1.0 and the scale-CVI was 1.0) and good convergent validity (higher levels of stigma were significantly associated with higher levels of depressive symptoms). Finally, the reliability of the measure was also found to be adequate (alpha = 0.79).

Conclusions:

The initial examination of the Breast Cancer Stigma Scale for Arab Patients indicated that the scale is both valid and reliable to be used in Arab women with breast cancer.

Cancer-Related Stigma and Depression in Cancer Patients in A Middle-Income Country

Objective:

The aim of the current study are to determine the depression levels of adult oncology patients in the cancer treatment phase and identify both cancer-related stigma and the factors affecting their depression levels.

Methods:

In this correlational study, 303 adult patients who had been treated at a medical outpatient clinic were surveyed using the convenience sampling method. The “questionnaire for measuring attitudes toward cancer – patient version,” a sociodemographic characteristics questionnaire, and the beck depression inventory were used. A multivariable linear regression model was used for the analysis.

Results:

The questionnaire and its subscale scores indicated a positive relationship between depression and attitudes toward cancer. The predictive variables for depression were “being younger than 40-year-old” and “feelings of social exclusion,” which accounted for 4% of the total variance. Four factors indicating negative attitudes toward cancer were “being more than 60-year-old,” “higher education,” “low income,” and “feelings of social exclusion,” which accounted for 11% of the total variance.

Conclusions:

Cancer-related stigma, which underlies patients' emotional and behavioral outlooks, should be reduced in cancer patients. Members of health teams should be sensitive to cancer-related stigma.

Stigma and Related Factors in Iranian People with Cancer

Introduction: Stigma is one of the psychosocial and intercultural issues that can be found in chronic diseases, including cancer. Stigma may reduce communication due to social isolation, feeling shame and others’ judgment, and these factors make far from professional services and poor health outcomes in individuals with cancer. Assessment of stigma can help determine and recognize the overall levels of stigma in the community and identify situations that need intervention. Objective: The aim of this study was to determine stigma and related factors in individuals with cancer in Iran. Methods: This descriptive cross-sectional study was conducted on 142 patients with cancer selected via convenience sampling method in two hospitals affiliated to Shahid Beheshti Medical University. A demographic as well as clinical record form and “A questionnaire for measuring attitudes toward cancer (cancer stigma) ‑ Patients version” by Cho et al., (2013) were used for data collection. Data were analyzed using descriptive statistics and regression analysis. Results: More than one quarter of participants (26.1%) had negative attitudes toward cancer and high stigma score>= 2.5. More than half of the participants (57.5%) agreed that their job performance would be reduced even after treatment. 54.5% of the patients considered it difficult to regain health after being diagnosed. There was a significant correlation between the stigma score and the level of education (p= 0.033, OR=0.78). Conclusion: The results showed that stigma in dimensions of impossibility of recovery and stereotypical aspects of cancer were more common. These findings can lead to interventions and educational efforts on cancer coherence which may help in treatment, rehabilitation and return to normal life.