Reliability and Validity of the Korean Version of the Cancer Stigma Scale

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1 ORIGINAL ARTICLE ISSN (Pint) ISSN (Online) X J Koean Acad Nus Vol.47 No.1, 121 Reliability and Validity of the Koean Vesion of the Cance Stigma Scale So, Hyang Sook 1 Chae, Myeong Jeong 2 Kim, Hye Young 3 1 College of Nusing, Chonnam Reseach Institute of Nusing Science, Chonnam National Univesity, Gwangju 2 Depatment of Nusing, Kwangju Women s Univesity, Gwangju 3 College of Nusing Reseach Institute of Nusing Science, Chonbuk National Univesity, Jeonju, Koea Pupose: In this study the eliability and validity of the Koean vesion of the Cance Stigma Scale (KCSS) was evaluated. Methods: The KCSS was fomed though tanslation and modification of Cataldo Lung Cance Stigma Scale. The KCSS, Psychological Symptom Inventoy (PSI), and Euopean Oganization fo Reseach and Teatment of Cance Quality of Life Questionnaie - Coe 30 (EORTC QLQ-C30) wee administeed to 247 men and women diagnosed with one of the five majo cances. Constuct validity, item convegent and disciminant validity, concuent validity, known-goup validity, and intenal consistency eliability of the KCSS wee evaluated. Results: Exploatoy facto analysis suppoted the constuct validity with a six-facto solution; that explained 65.7% of the total vaiance. The six-facto model was validated by confimatoy facto analysis (Q (c 2 /df)= 2.28, GFI=.84, AGFI=.81, NFI=.80, TLI=.86, RMR=.03, and RMSEA=.07). Concuent validity was demonstated with the QLQ-C30 (global: =-.44; functional: =-.19; symptom: =.42). The KCSS had known-goup validity. Conbach s alpha coefficient fo the 24 items was.89. Conclusion: The esults of this study suggest that the 24-item KCSS has elatively acceptable eliability and validity and can be used in clinical eseach to assess cance stigma and its impacts on health-elated quality of life in Koean cance patients. Key wods: Social stigma; Neoplasms; Validity and eliability INTRODUCTION Cance is the leading cause of death in men and women woldwide. Cance incidence was at 224,177 with the five-yea suvival ate epoted 69.4% in 2013 in Koea [1], while in the United States, it was 69.0% in 2011 [2]. With cance patient suvival ates inceasing, national policy and clinical eseaches have begun to focus on the management of psychological distess and quality of life of cance patients [3]. Moe than 30.0% of cance suvivos have a negative attitude towad cance, and the cance patients who expeienced a stigma towad cance showed moe than 2.5 times highe ates of depession compaed to cance patients with positive attitude towad cance without a stigma [4]. Stigma was linked to guilt and shame, self-blame, blame attibution, and depession, and in cance eseach, these concepts wee associated with one anothe [5,6]. Stigma may have popeties contay to social identity and, theefoe, those with cance may feel undevalued o tagged, and may expeience negative steeotyping and discimination, which togethe lead to social ejection, social isolation, lack of social suppot, and low social status [7]. In paticula, health-elated stigma (HRS) epesents expeiencing ejection, blame, o devaluation due to his o he illness [8,9]. HRS has been associated with illness-induced stess and contibuting to psychological, physical, and social mobidity [9,10]; such that a negative psychosocial impact esults in depession, eceiving * This study was financially suppoted by Chonnam National Univesity (Gant numbe: ). Addess epint equests to : Kim, Hye Young College of Nusing Reseach Institute of Nusing Science, Chonbuk National Univesity, 567 Baekje-daeo, Deokjin-gu, Jeonju 54896, Koea Tel: Fax: tcellkim@jbnu.ac.k Received: May 6, 2016 Revised: Octobe 26, 2016 Accepted: Novembe 1, 2016 This is an Open Access aticle distibuted unde the tems of the Ceative Commons Attibution NoDeivs License. ( If the oiginal wok is popely cited and etained without any modification o epoduction, it can be used and e-distibuted in any fomat and medium Koean Society of Nusing Science

2 122 So, Hyang Sook Chae, Myeong Jeong Kim, Hye Young limited social suppot, deceased teatment adheence, and advese teatment effects [11]. Because HRS can be an obstacle to seeking pofessional help and health pomotion activities [8], it is impotant fo both clinical eseach and pactice pofessionals to use a valid and eliable tool to peiodically evaluate cance patients fo HRS and effectively manage HRS. As cance can be a fatal disease, it is vey impotant to find inteventions to impove psychosocial and physical health fo cance suvivos to help them avoid long-tem ill-effects and possible death. Thee ae inceasing empiical studies on how stigma affects cance suvivos [12]. Although eseaches found the fact that cance stigma affects individuals with cance, most of the studies focus on patients with lung cance [8,11,13,14]. Van Bakel [9] epoted that many instuments have been developed to assess the intensity and qualities of stigma, but these ae often condition-specific including cance type-specific. Stigma has an effect on individuals and thei families, as well as on the effectiveness of health pogams. The similaity in the consequences of stigma in many diffeent cance s types [12] suggests that the development of geneic instuments to assess HRS of all types of cance patients may be possible [9]. Though a liteatue eview of 63 eseach papes that addessed the issues elated to measuing stigma o stigmaelated constucts, and that contained a sample of the instument o items used, aspects of HRS can be gouped into five categoies. Fist, the expeience of actual discimination and/o paticipation estictions on the pat of the peson affected; second, attitudes towads the people affected; thid, peceived o felt stigma; fouth, self o intenalized stigma; and fifth, disciminatoy and stigmatizing pactices in health sevices, legislation, media and educational mateials [9]. While Cataldo Lung Cance Stigma Scale (CLCSS) developed by Cataldo et al. [13] is a multidimensional measuement tool that can measue all aspects of HRS, it was developed to measue the peceived stigma of lung cance patients. It consists of fou subscales, stigma and shame domain, social isolation domain, discimination domain, and smoking status domain and it has been epoted to have a satisfactoy level of validity and high eliability at the time of development. In a study of cance-elated stigma by Else-Quest et al. [12], it was epoted that cance patients including patients with lung cance have intenal causal attibutions whee they believe cance occued due to thei hamful lifestyle habits. So, most cances can conjue a simila attibution of blame as is found with lung cance because most cances ae fequently associated with individual s behavios. Because of the lack of a valid and eliable tool, empiical evidence of cance-elated stigma is limited. Thus, to develop a geneic cance stigma scale, the existing instuments should be futhe validated, developed, o adapted fo geneic use, whee possible. In paticula, the measuement tools fo cance stigma wee as follow: (a) a single item fo peceived stigma, People judge me fo my type of cance, was ated 1 (stongly disagee) to 5 (stongly agee) [12]; and (b) CLCSS [13]. The CLCSS has been used in Koea and China [8,15]. The CLCSS was adapted to 123 lung cance patients without testing the validity in the Koean patient population [8]. Theefoe, we modified the CLCSS to fom the Koean Cance Stigma Scale (KCSS) and conducted a study to test the validity of the KCSS in patients with one of the five majo types of cance in Koea (beast, colon, lung, stomach, and uteine cevix cance). This pape is to epot the validity and eliability of the KCSS. METHODS 1. Study design The study was a coss-sectional suvey design using a convenience sample and self-administeed questionnaie. 2. Paticipants and data collection The convenience sample used in this study was compised of 247 inpatients and outpatients (18 yeas o olde) diagnosed with beast, colon, lung, stomach, o uteine cevix cance. As of 2013, when it comes to cance incidence in Koean men and women, fequency is in the ode of gastic, colon, lung, live, postate, and thyoid gland in men and thyoid gland, beast, colon, gastic, lung, live, uteine cevix in women [1]. When it comes to cance locations to select fo the eseach paticipants, beast cance which is the second place in women and uteine cevix cance which is the seventh place wee selected to have the same atio of gende, togethe with gastic cance, colon cance, and lung cance patients which ae common cances fo both men and women. Thyoid cance was excluded fom this study because the

3 Reliability and Validity of the Koean Vesion of the Cance Stigma Scale 123 pognosis is excellent compaed to othe types of cance while it anks in the sixth place in men and fist place in women. This study was conducted at C National Univesity H Hospital cance cente in C Povince, Koea. Thee tained inteviewes collected data. In ode to conduct the exploatoy facto analysis (EFA) and confimatoy facto analysis (CFA) fo the constuct validity veification, the numbes of paticipants that ae equied is at least 200 o 4 times of numbe of items [16]. The sample size in this study was 247 fo 31 items, thus, satisfied the equiements fo sample size. 3. Instuments 1) Cance stigma: The Koean Cance Stigma Scale (KCSS) The CLCSS, developed in 2011 [13], includes 31 items and 4 subscales: stigma and shame, social isolation, discimination, and smoking status. Each stigma item was measued using a foupoint Liket-type scale anging fom 1 (stongly disagee) to 4 (stongly agee) with the highe scoes indicating a stonge stigma peceived by the patient. The possible scoes anged fom 31~124. Coefficient alphas anged fom.75 to.97 fo the subscales (.97 fo stigma and shame,.96 fo social isolation,.92 fo discimination, and.75 fo smoking status) and.96 fo the oveall CLCSS. The KCSS was fomed using the cultual adaptation pocesses suggested by the Wold Health Oganization [17]. Fist, afte obtaining pemission to tanslate the CLCSS and modify the items so that they could be applied to the five majo types of cance patients in Koea, two bilingual nusing pofessos tanslated the CLCSS fom English to Koean and poduced a peliminay daft. The daft undewent a pocess of convegence though mutual discussion egading diffeences. The tanslated daft was then back-tanslated to English by an English expet. A compaison was made between the oiginal and back-tanslated CLCSS which yielded no substantial diffeences. Second, the tem lung cance was changed to cance fo 31 items. Item No. 10, Smokes could be efused teatment fo lung cance was changed to Cance patients who have high isk factos (i.e., smoking, obese, salty food intake, genetic, etc.) could be efused cance teatment and the item No. 30, Healthcae povides don t take smoke s cough seiously was changed to Healthcae povides don t take cance patients signs seiously (i.e., coughing fo lung cance, constipation fo colon cance, lumps fo beast cance, abnomal bleeding fo cevix cance, and gastic fullness and indigestion fo stomach cance). Also, changes wee made in item No. 28, stop smoking and item No. 29, smoking cessation by combining No 28 with Item No. 29 as, Despite not usually having hamful lifestyle habits, people think it was my fault that I had a cance. Theefoe, in the total of 31 items of the oiginal CLCSS, items 28 and 29 wee evised to 29, and the inteim vesion of the KCSS had a final of 30 items. Thid, fo veification of the content validity fo the inteim vesion of the KCSS which went though the pocess of tanslation and back-tanslation, we selected the pofessional goup of thee nusing pofessos and one oncology nuse as suggested by Lynn [18]; that is the desiable numbe of pofessionals fo content validity veification should be moe than 3 but less than 10. The validity of each item was designed to be assessed fom scoe 4 of Stongly agee to scoe 1 of Stongly disagee, then calculation was done fo the content validity index (CVI) of each item. As a esult, all of CVI of 30 items wee above 80.0%. Fouth, to test feasibility, fifteen patients with five types of cance wee tested using the scale as a pilot test. Futhe evisions of vocabulay and claity wee made based on the feedback of the 15 patients to geneate the final scale; this took about 10 minutes fo the questionnaie esponses. Patients esponded to each item using a 4-point Liket scale with the highe scoes epesenting stonge stigma peceived by the patient. The total scoe of the KCSS anged fom 30 to ) Quality of life: Euopean Oganization fo Reseach and Teatment of Cance Quality of Life Questionnaie-Coe 30 (EORTC QLQ-C30) To evaluate the concuent validity of the KCSS, we used the Koean vesion of the quality of life questionnaie (QLQ-C30) vesion 3.0 [19]; pemission to use the instument was obtained via electonic communication. Accoding to pevious studies, the quality of life of cance patients is closely linked to cance stigma; that is, the wose the quality of life, the geate the cance stigma the patient pesents [8,12,14]. The QLQ-C30 seems to be an adequate instument to veify the concuent validity of the KCSS because the degee of peceived cance stigma suffeed by

4 124 So, Hyang Sook Chae, Myeong Jeong Kim, Hye Young patients with cance can affect thei peceptions of cance-elated quality of life. This instument included thee subscales: global health status (2 items), functional (15 items assessing physical, ole, emotional, cognitive, and social aspects), and symptom (13 items assessing fatigue, nausea and vomiting, pain, dyspnea, insomnia, appetite loss, constipation, diahea, and financial poblems). The two global health status-elated items wee scoed using a 7-point scale, and the functional and symptom-elated items wee scoed using a 4-point scale. The scoes wee conveted to a 100-point scale accoding to the scoing manual [20] and the scoes anged fom 0~100, with QOL inceasing in popotion to the global health status and functional subscale scoes; in contast, the lowe the symptom subscale scoe, the highe the QOL. In a study by Yun and colleagues [19], the Conbach s alpha coefficient was.70 o highe in all but the cognitive functional scale (.60). In this study, the Conbach s alphas wee.80,.87, and.84 fo the global health status, functional, and symptom subscales, espectively. 3) Psychological distess: Psychological Symptom Inventoy (PSI) To evaluate the known-goup validity of the KCSS, we used Koean vesion of the psychological symptom inventoy (PSI) developed by the National Cance Cente [3] which measue psychological distess that was poposed as closely elated vaiables to the cance stigma in pevious studies [4,5,8,11,14], and use of the instument was confimed though an . The PSI assessed the cuent distess levels of thee symptoms and intefeence with daily activities (insomnia, anxiety, and depession). Insomnia, anxiety, and depession domain consists of one question of symptom-elated seveity and one question of intefeence with daily activity espectively and each item configued by domain was measued using a bipola ancho scale anging fom 0 (absolutely not o no disupting daily life) to 10 (extemely sevee o completely disupting daily life). It means that the scoe ange fo each domain is fom 0 to 20 and the highe the scoe, the highe insomnia, anxiety, and depession. When the cut-off scoe fo each domain is 4 o moe in both seveity and intefeence, it means that thee is psychological distess. In the pesent study, Conbach s alpha was.83 in insomnia and intefeence with daily activity,.84 in anxiety and its intefeence, and.88 in depession and its intefeence. 4. Ethical consideations The study pocedues wee appoved by the institutional eview boad (IRB) of C National Univesity H Hospital, located in C Povince (IRB No ). Afte eading the infomed consent fom and giving witten consent, submission of the completed questionnaies implied that paticipants consented to paticipate in this study. Ethical consideation infomation about the eseach was given to these paticipants. 5. Data analysis Desciptive statistics and appopiate eliability and validity statistical tests wee used with SPSS vesion 21.0 and Amos Desciptive statistics wee used to establish the fequency, ange, mean, and standad deviation of the demogaphic and clinical chaacteistics of the main sample. Fo eliability assessment, Conbach s alpha coefficients wee conducted. Fo the validity assessment, constuct validity, item convegent and disciminant validity, concuent validity, and known-goup validity wee evaluated. Fo constuct validity, EFA and CFA wee pefomed. Fist, we conducted KMO (Kaise- Meye-Olkin) and Batlett Spheicity test in ode to confim whethe the mateials that wee collected pio to the facto analysis ae appopiated fo facto analysis. We used the eigenvalue of one and above fo the facto extaction by the EFA, cumulative pecentage 60.0% and above fo vaiance that is explained by the extacted factos, and.50 and above fo facto loading citeion [21]. The model vei cation of CFA can be conducted on the basis of the Q (c 2 /df), GFI (goodness of fit index), AGFI (adjusted goodness of fit index), NFI (nomed fit index), TLI (Tucke-Lewis coefficient), RMR (oot mean squae esidual), and RMSEA (oot mean squae eo of appoximation). It is acceptable when Q value is 3.0 o less and the model fit is judged to be good if GFI, AGFI, NFI, and TLI ae.90 o geate and RMR is.05 o less [22]. And RMSEA is a good model if it is below.05 and if it is.05 to.08, it is consideed to be a suitable model [21]. To test convegent and disciminant validity of KCSS items, multi-tait multi-item matix analysis was implemented. In

5 Reliability and Validity of the Koean Vesion of the Cance Stigma Scale 125 multi-tait multi-item matix analysis, item convegent validity was judged satisfied if item subscale coelation coected fo ovelap fo coefficients should be.40 o geate [23], and also in item disciminant validity, disciminant validity was judged satisfactoy if the diffeence between the item-own and itemothe subscale coelation is geate than 2 times the standad eo of coelation coefficients, it can be consideed that the item disciminant validity is established [23,24]. Concuent validity was detemined by calculating Peason coelation coefficients fo elationships between the 24-item KCSS and subscales of QLQ-C30. To assess the known-goup validity of the instument, the diffeences in KCSS scoes accoding to the distess goup classification wee analyzed with independent t-test. All tests used wee two-sided, and a p value of less than 5% was consideed statistically significant. In total, 247 data wee analyzed. RESULTS 1. Sample chaacteistics and desciptive data The study sample compised 247 patients; 20.6% had beast cance; 20.2%, colon cance; 20.2%, uteine cevical cance; 20.0%, gastic cance; and 19.0%, lung cance. The aveage age was (SD=12.25 yea, ange 24~85 yeas old), 60.3% wee women, 87.0% wee maied, 65.6% had a eligion, and 78.9% had a job. Educational level was 36.8% with high school gaduation and 23.5% with middle school gaduation. At the time of the suvey, 58 patients (23.5%) wee diagnosed with stage I disease, 41 (16.6%) had stage II disease, 47 (19.0%) had stage III disease, and 101 (40.9%) had stage IV disease. Types of cuent teatment epoted wee anticance chemotheapy (68.5%) and opeation and adiation theapy (14.0% o moe each). Responses fo each psychometic vaiable (i.e., KCSS, QLQ-C30, and PSI) wee positively skewed. Paticipants esponded with a positive tendency fo stigma. The floo effect in each subscale of KCSS anged fom 4.2% to 14.8%, and the ceiling effect anged fom 0.4% to 0.8%, and had less than 15.0% which is acceptable citeia in all subscales [25]. Also the skewness of each KCSS item anged fom to 2.62 and kutosis anged fom to In this study, as skewness was not geate than the absolute value 3 and kutosis was not geate than the absolute value 10, it has been confimed that it does not deviate fom the univaiate nomal distibution [26]. The total stigma scale (KCSS) scoe was 35.28±9.12. Quality of life (QLQ-C30) was modeate; the global QOL scoe was 54.86±20.26, and the symptom QOL and functional QOL wee 28.69±16.34 and 71.02±16.42, espectively. The scoe of distess (PSI) was aveage of 5.04±2.61 fo insomnia, 4.92±2.35 fo anxiety, and 4.54±2.53 fo depession. 2. Validity of the KCSS 1) Constuct validity (1) Exploatoy facto analysis To test fo the adequacy of the sample size, the authos examined the coelation matix using the KMO [27]; the values of KMO of the fist 30 items and last 24 items wee.84 and.86 (p<.001), which wee all appopiate. The Batlett Spheicity test is used to evaluate whethe the coelation matix is fit fo the facto analysis [21]; the chi-squaed was (degee of feedom=276), which was statistically significant (p<.001), indicating that facto analysis of KCSS was appopiate. We used the pincipal component facto analysis as facto extact model that is mainly used to minimize the infomation loss with the minimum facto aiming the foecast and used vaimax otation that classifies the factos by maximizing the sum of facto loading vaiance and clea the facto popety at the most [21]. The initial un of the EFA using an eigenvalue cuve indicates eight eigenvalues in the scee plot above the mean eigenvalue, so these eight factos wee etained. Afte vaimax otation, one item (No. 7) with a facto loading of <.40 was deleted and items with a facto loading of <.50 wee deleted (Items No. 2, 10, 20, 24, 26). Rotation was again pefomed and six factos wee extacted; these factos could explain 65.7% of the total vaiance. KCSS showed 24 items and 6 sub-factos (social isolation, distancing o avoiding, disciminating, guilt, attibution, and lack of medical suppot) (Table 1). (2) Confimatoy facto analysis The esult of evaluating the fit of the stuctual equation model consisting 24 items and 6 factos was shown as c 2 = (p<.001), Q (c 2 /df)=2.28, GFI=.84, AGFI=.81, NFI=.80, TLI=.86

6 126 So, Hyang Sook Chae, Myeong Jeong Kim, Hye Young RMR=.03, and RMSEA=.07. While Q value was 3.0 o less, RMR was.05 o less and RMSEA was.05 to.08 so that they met the ecommended level, the emaining indexes did not meet the.90 o geate which is the ecommended level. Factos wee named depending on the pime item of loading to the facto (Table 1). Facto 1. Social isolation subscale: The fist facto compised five items with loadings anging fom.81~.68. Item No. 11 was I have lost fiends by telling them I have cance. Item No. 13 was People have physically backed away fom me. Facto 2. Distancing o avoiding subscale: The second facto compised fou items with loadings anging fom.76~.68. Item No. 17 was People avoid touching me if they know I have cance. Item No. 19 was Some people who know have gown moe distant. Facto 3. Discimination subscale: The thid facto compised fou items with loadings anging fom.78~.57. Item No. 22 was People with cance ae teated like outcasts. Item No. 21 was I woy about people disciminating against me. Facto 4. Guilt subscale: The fouth facto compised five items with loadings anging fom.77~.48. Item No. 3 was Having cance makes me feel like I m a bad peson. Item No. 1 was I feel guilty because I have cance. Facto 5. Attibution subscale: The fifth facto compised thee items with loadings anging fom.76~.73. Item No. 27 was Cance is viewed as a self-inflicted disease. Item No. 29 was Othes assume that cance was caused Table 1. Facto Loading of the KCSS with Pincipal Component Facto Analysis with Vaimax Rotation * Factos Factos Items I II III IV V VI I. Social isolation Item Item Item Item Item II. Distancing o avoiding Item Item Item Item III. Discimination Item Item Item Item IV. Guilt Item Item Item Item Item V. Attibution Item Item Item VI. Lack of medical suppot Item Item Item Eigen values Popotion of vaiances (%) Total Vaiances (%) Conbach s alpha Total Conbach s alpha =.89 KCSS=Koean vesion of the Cance Stigma Scale. * Items 2, 7, 10, 20, 24, and 26 wee deleted as facto loading was less than.40. Items 28 and 29 in oiginal tool wee evised and meged into item 29 in the pocess of applying tool fo the five majo Koean cances.

7 Reliability and Validity of the Koean Vesion of the Cance Stigma Scale 127 by the patient s bad habits, even if he o she neve had those habits. Facto 6. Lack of medical suppot subscale: The sixth facto compised thee items with loadings anging fom.89~.43. Item No. 9 was My cance diagnosis was delayed because my health cae povide did not take my symptoms seiously. Item No. 30 was Healthcae povides don t take cance patients signs seiously (i.e., coughing fo lung cance, constipation fo colon cance, lumps fo beast cance, abnomal bleeding fo cevix cance, and gastic fullness and indigestion fo stomach cance). 2) Convegent and disciminant validity of KCSS items In this study, multi-tait multi-item matix analysis was caied out in ode to test convegent and disciminant validity of KCSS items. The esult showed that the item subscale coelation coected fo ovelap fo coefficients anged fom.41 to.69 so that all wee.40 o geate. The success ate of the convegent validity of the item was 100%. Also in item disciminant validity, the item-own subscale coelations wee highe than the itemothe subscale coelations, and most item-own subscale coelations exceeded item-othe subscale coelations by 2 times the standad eo of coelation coefficients except fo items 29 and 8. The scaling success ate was calculated by dividing the numbe of the item-othe subscale coelations by moe than 2 times of the standad eo of the coelation coefficients by the total numbe of the item-othe subscale coelations accoding to the method of Fayes and Machin [23], esulting in 97.5% (Table 2). And also, Conbach s alpha coefficients of each subscale wee highe than the coelation coefficients among the othe subscales. Thus, it was confimed that the popeties of each subscale wee disciminated [28] (Table 3). Table 2. Multi-Tait Multi-Item Matix (Coelation Matix Coected fo Ovelap) fo Convegent and Disciminant Validity of KCSS Items Factos Factos Items No. I II III IV V VI 2 Standad eo I. Social isolation Item **.38 **.33 **.38 ** **.088 Item **.50 **.48 **.42 **.22 **.25 **.085 Item **.55 **.49 **.34 **.20 **.27 **.065 Item **.60 **.53 **.37 **.29 **.21 **.076 Item **.39 **.46 **.26 **.17 ** II. Distancing o avoiding Item **.55 **.40 **.29 **.17 **.23 **.069 Item **.47 **.35 **.27 **.23 **.19 **.060 Item **.66 **.46 **.39 **.18 **.19 **.063 Item **.64 **.50 **.38 **.18 **.16 *.069 III. Discimination Item **.46 **.61 **.31 **.28 **.17 **.064 Item 21.44**.41 **.69 **.35 **.37 **.33 **.087 Item **.32 **.49 **.39 **.39 **.39 **.084 Item **.30 **.50 **.32 **.27 ** IV. Guilt Item 3.30 **.32 **.27 **.62 **.14 *.22 **.102 Item 5.20 **.17 **.21 **.49 **.15 *.20 **.087 Item 4.28 **.30 **.33 **.63 **.26 **.38 **.110 Item 1.36 **.33 **.38 **.54 **.23 **.30 **.113 Item 6.42 **.41 **.41 **.53 ** **.108 V. Attibution Item *.16 *.24 **.17 **.43 **.27 **.112 Item **.28 **.47 **.24 **.48 **.40 **.085 Item **.14 *.30 **.14 *.42 **.22 **.116 VI. Lack of medical suppot Item 9.15 *.16 *.19 **.25 ** **.106 Item *.14 *.25 **.27 **.33 **.45 **.101 Item 8.31 **.24 **.40 **.34 **.32 **.43 **.109 KCSS=Koean vesion of the Cance Stigma Scale. **p<.01; * p<.05.

8 128 So, Hyang Sook Chae, Myeong Jeong Kim, Hye Young Table 3. Reliability Coefficients and Inte-subscale Coelations Subscales Subscales I II III IV V VI I. Social isolation (.86) II. Distancing o avoiding.59 (.80) III. Discimination (.80) IV. Guilt (.79) V. Attibution (.64) VI. Lack of medical suppot (.62) ( )=Conbach s alpha of each subscale. Table 4. Coelations between 24-item KCSS and Subscales of QLQ-C30 fo Concuent Validity Subscales in QLQ-C30 3) Concuent validity 24-item KCSS (p) Global subscale -.44 (<.001) Functional subscale -.19 (.003) Symptom subscale.42 (<.001) KCSS=Koean vesion of the Cance Stigma Scale; QLQ-C30=Cance Coe Quality of Life Questionnaie-30 items. Concuent validity was assessed by examining the elationship of KCSS with the QOL scale (EORTC QLQ-C30). KCSS has a statistically significant negative coelation with global and functional subscales of the QLQ-C30 espectively (=-.44; =-.19), and KCSS has a statistically significant positive coelation with symptom subscale of the QLQ-C30 (=.42) (Table 4). 4) Known-goup validity To test the known-goup compaisons, the PSI subscales (insomnia, anxiety, and depession) wee categoized by two goups egading cut-off scoe (4 points). Fo each psychological symptom, seveity and intefeence s scoe wee classified into distess goup with 4 points o moe and non-distess goup with less than 4 points. In insomnia, anxiety, and depession domains, the distess goup had a significantly highe peceived cance stigma than the non-distess goup, espectively (t=2.28, p=.024; t=4.63, p<.001; t=4.43, p<.001) (Table 5). The KCSS scoe of patients with coloectal cance was highest among the five types of cance; howeve, thee wee no diffeences fom the KCSS scoes between the five types of cance patients (coloectal cance 38.20±11.30, beast cance 33.94±7.71, lung cance 35.55±9.16, cevix cance 35.28±8.40, gastic cance 33.76±8.00; F=1.96, p>.999). 3. Reliability of the KCSS Conbach s alpha fo the KCSS with 24 items was.89; fo the six subscales, and anged fom.62~.86 (Table 1). DISCUSSION KCSS was developed to measue the cance-elated stigma that can be expeienced in the illness tajectoy pocess of cance patients. The findings in this study povide a pimay basis fo the eliability and validity that the tool, though veifications of Koean vesion KCSS such as content validity, constuct validity, item convegent and disciminant validity, concuent validity, knowngoup validity, and eliability. As a esult, the six factos that emeged in this analysis wee eflected in the six subscales: social isolation, distancing o avoiding, discimination, guilt, attibution, and lack of medical suppot. The eliability of fou subscales of the oiginal vesion of the CLCSS fo lung cance as epoted was that the Conbach s alpha coefficient was.96 fo 31-item instument and anged fom.75 to.97 [13]. In this study, the Conbach s alpha coefficient was.89 fo the oveall instument and anged fom.62 to.86 fo each subscale. Thus, the eliability of the measued vaiable satisfied the standad of.70 [29] except fo attibution (.64) and lack of medical suppot (.62) subscales. These esults wee simila to those of Chinese vesion of the CLCSS [15] which epoted Conbach s alpha coefficients between.60 and.88 fo lung cance

9 Reliability and Validity of the Koean Vesion of the Cance Stigma Scale 129 Table 5. Known-goup Compaisons of 24-item KCSS Scoes between Distess and Non-distess Goups of PSI 24-item KCSS Subscales in PSI Goups n M±SD t (p) Insomnia Distess ( 4 points) ± (.024) Non-distess (<4 points) ±7.60 Anxiety Distess ( 4 points) ± (<.001) Non-distess (<4 points) ±7.83 Depession Distess ( 4 points) ± (<.001) Non-distess (<4 points) ±7.67 PSI=Psychological Symptom Inventoy; KCSS=Koean vesion of the Cance Stigma Scale. patients. As Conbach s alpha coefficients fo the oveall instument wee shown to be elatively high and above the standad of.70 [29], this esult ensues the eliability of the instument. Howeve, the attibution subscale and the lack of medical suppot subscale among the KCSS sub-factos should be eaffimed though a test-etest eliability veification study in the futue. In the two studies using CLCSS that wee intended fo lung cance patients, the same fou factos wee extacted [13,15]. In the oiginal measue fo lung cance, the fou factos wee stigma and shame, social isolation, discimination, and smoking status by EFA, explaining 57.0% of the total vaiance; the final vesion compised 31 items [13]. The findings of Yang et al. [15] study with Chinese lung cance patients wee the same as the esults epoted by Cataldo et al. [13] and the amount of total vaiance explained was 58.6% fom the fou factos extacted by EFA. In this study, the total vaiance explained was 65.7% so that it was highe than the total vaiance of the oiginal CLCSS and Chinese vesion CLCSS. Theefoe, KCSS is detemined as a vey useful measue of stigma fo Koean cance patients. Howeve, as the KCSS was made with modified tems of the items to apply it to five types of cance patients wheeas the CLCSS tagets lung cance patients only, thee may be patly limitation of validity. The item distibution by subscale of 24-item KCSS and item distibution of oiginal 31-item CLCSS ae to be eviewed. Guilt subscale and lack of medical suppot subscale items of KCSS wee stigma and shame subscale in the oiginal CLCSS, social isolation subscale and distancing o avoiding subscale items of KCSS wee social isolation subscale in the oiginal CLCSS, discimination subscale items of KCSS wee discimination subscale in the oiginal CLCSS and attibution subscale items of KCSS wee smoking status subscales in the oiginal CLCSS so that the simila item distibutions wee seen. That is, the oiginal CLCSS has fou subscales and the KCSS has six subscales so that the subscale might be futhe subdivided and the item distibution was simila with item distibution by subscales in oiginal CLCSS. Howeve, fo the lack of medical suppot which is the sixth subscale of KCSS, item 9 was located in the smoking status of the oiginal CLCSS and item 30 and 8 wee located in the stigma and shame of the oiginal CLCSS. This means that the facto stuctue can be changed fo each suvey that vaies by taget goup and sample numbe and especially, as lung cance is changed to cance fo all sentences in the study, it could be because smoking status subscale of oiginal CLCSS disappeaed and seveal wodings wee modified to use with the five types of cance. Fo this study constuct validity, item convegent and disciminant validity, concuent validity, and known-goup validity wee used as methods of testing validity. To test constuct validity, c 2, Q (c 2 /df), GFI, AGFI, NFI, TLI, RMR, and RMSEA wee calculated though CFA. The c 2 assesses whethe the actual data coesponds to the model in CFA. Howeve, when the sample size inceases, it geneally becomes significant. Thus, many othe suitability indicatos in addition to c 2 wee examined. Q, RMR and RMSEA met the ecommended level among the fitness index, but the GFI, AGFI, NFI, and TLI didn t meet.90, the ecommended level of the best-fit model in this study. It is not desiable in the evaluation of CFA esult model fo constuct validity to judge the model by elying only on a single fit index and seveal fit indexes should be consideed at the same time [21]. Theefoe, in this study, a measuement model consisting of 24 items and 6 subscales was accepted in the end. Howeve, thee was the esult seen that the validity of the CFA esult model fo constuct

10 130 So, Hyang Sook Chae, Myeong Jeong Kim, Hye Young validity did not meet some citeia in this study. Theefoe, in ode to establish stability of constuct validity, e-test should be done though follow-up study. In this study, the esults of veifying item convegent and disciminant validity by multi-tait multi-items matix analysis have showed 100% convegent validity and 97.5% disciminant validity of KCSS items. Items 29 and 8 wee within the citical value of othe subscales items. This may mean that items 29 and 8 could be affected o confounded by othe subscales. Howeve, Conbach s alpha coefficient of each subscale was highe than the coelation coefficients among the othe subscales in this study, so that each subscale popeties wee disciminated [28]. Theefoe, it was shown that the measuement items consistently measue constuct concept and independent among subscales was maintained. In ode to veify the concuent validity, this study utilized the QLQ-C30 questionnaie to assess the cance-elated quality of life vaiables. In this study, significant coelations wee found between the 24-item KCSS and subscales of the QLQ-C30. Howeve, the ange of coelation coefficient fo the functional subscale of the QLQ-C30 and fo 24-item KCSS was -.19, falling shot of the ecommended ange fo coelation coefficients (=.40 to =.80) [30] to establish concuent validity. Such a low coelation is pesumed to be because the paticipants of this study wee those who wee in aggessive teatment and about 69% of them ae cuently on anticance chemotheapy so that it seems that thee could be some limit fo the stigma caused by cance to influence the functional level of the paticipant compaed to the global health status and teatment-elated symptoms. In ode to test the known-goup compaisons, we used two methods: compaison methods of the KCSS scoes between (1) five types of cance sites, and (2) the distess and non-distess goups of the PSI scoes. The KCSS scoe of patients with coloectal cance patients was the highest; lung, cevix, beast, and gastic cance followed in ode. Howeve, thee wee statistically no diffeences fom the KCSS scoes between the five types of cance patients. Theefoe, the 24-item KCSS could potentially be applied to Koean cance patients. As HRS that the cance patients expeience in the pocess of cance teatment and its ecovey means ejection, blame, o devaluation due to his o he illness [9,10], HRS elated to the illness may incease the degee of psychological distess in cance patients [5], it is consideed that psychological distess is pope eseach vaiable fo the known-goup validity veification of KCSS. Hence, a significant diffeence in the stigma scoes of the goups with diffeent psychological distess levels establishes the known-goup validity of the KCSS. This eseach analyzed the diffeences in the KCSS mean scoes fo each goup accoding to the distess and non-distess goups of PSI scoes. In this study, the KCSS scoe had a statistically significant diffeence between the distess and non-distess goup fo the PSI scoes; the distess goups of insomnia, anxiety, and depession domains had a significantly highe peceived cance stigma than the non-distess goups. Thus, the known-goup validity of the KCSS instument was established. Howeve, the limitation of this eseach is that it did not test esponsiveness, which evaluates the change in degee of patientepoted cance stigma ove time. Theefoe, thee is a need to test the esponsiveness though a futue longitudinal study. And also, as this study investigated cance patients in only one city, it is suggested that futhe studies should be conducted on cance patients in vaious egions in ode to genealize KCSS in clinical pactice. Lastly, as KCSS is a tool to be applied to the five types of cance patients, we suggest the necessity of cance-specific o sensitive stigma tool development in the futue. CONCLUSION Cance stigma is a vey impotant psychological concept that cance patients can expeience duing diagnosis and teatment and it affects patients daily lives so that it is vey impotant to objectively evaluate the cance stigma peceived by patients in the clinical fields. Theefoe, this study was conducted to test the eliability and validity of KCSS. The study esult has shown that the 24-item KCSS has a elatively acceptable eliability and validity. Howeve, in the CFA fo constuct validity, the fit of the model did not meet some citeia and thee wee two subscales (attibution subscale and lack of medical suppot subscale) which had elatively low Conbach s alphas. Theefoe, if these ae complemented by futhe studies, this tool will povide a useful instument in clinical tials investigating stigma, as well as its impact on the quality of life and psychosocial distess in Koean

11 Reliability and Validity of the Koean Vesion of the Cance Stigma Scale 131 cance patients. CONFLICTS OF INTEREST The authos declaed no conflict of inteest. REFERENCES 1. Ministy of Health & Welfae, Koea Cental Cance Registy, National Cance Cente. Annual epot of cance statistics in Koea in Seoul: Ministy of Health & Welfae; Ameican Cance Society. Cance facts & figues 2016 [Intenet]. Atlanta, GA: Autho; 2016 [cited 2016 Decembe 8]. Available fom: 3. National Cance Infomation Cente. Recommendations fo distess management in cance patients [Intenet]. Seoul: Ministy fo Health, Welfae and Family Affais; 2008 [cited 2012 May 20]. Available fom: 4. Cho J, Choi EK, Kim SY, Shin DW, Cho BL, Kim CH, et al. Association between cance stigma and depession among cance suvivos: A nationwide suvey in Koea. Psycho-Oncology. 2013;22(10): Phelan SM, Giffin JM, Jackson GL, Zafa SY, Hellestedt W, Stahe M, et al. Stigma, peceived blame, self-blame, and depessive symptoms in men with coloectal cance. Psycho-Oncology. 2013;22(1): Pineles SL, Steet AE, Koenen KC. The diffeential elationships of shame poneness and guilt poneness to psychological and somatization symptoms. Jounal of Social and Clinical Psychology. 2006;25(6): Lee I, Lee E. Concept analysis of stigma. The Jounal of the Koean Rheumatism Association. 2006;13(1): Lee JL, Kim KS. The elationships between stigma, distess, and quality of life in patients with lung cance. Jounal of Koean Oncology Nusing. 2011;11(3): Van Bakel WH. Measuing health-elated stigma; A liteatue eview. Psychology, Health & Medicine. 2006;11(3): Majo B, O Bien LT. The social psychology of stigma. Annual Review of Psychology. 2005;56: Shen MJ, Coups EJ, Li Y, Holland JC, Hamann HA, Ostoff JS. The ole of posttaumatic gowth and timing of quitting smoking as modeatos of the elationship between stigma and psychological distess among lung cance suvivos who ae fome smokes. Psycho-Oncology. 2015;24(6): Else-Quest NM, LoConte NK, Schille JH, Hyde JS. Peceived stigma, self-blame, and adjustment among lung, beast and postate cance patients. Psychology & Health. 2009;24(8): Cataldo JK, Slaughte R, Jahan TM, Pongquan VL, Hwang WJ. Measuing stigma in people with lung cance: Psychometic testing of the cataldo lung cance stigma scale. Oncology Nusing Foum. 2011;38(1):E46-E Chambes SK, Baade P, Youl P, Aitken J, Occhipinti S, Vinod S, et al. Psychological distess and quality of life in lung cance: The ole of health-elated stigma, illness appaisals and social constaints. Psycho-Oncology. 2015;24(11): Yang QQ, Liu HX, Yang CL, Ji SY, Li L. Reliability and validity of Chinese vesion of cataldo lung cance stigma scale. Intenational Jounal of Nusing Sciences. 2014;1(1): Coates C. The evolution of measuing caing: Moving towad constuct validity. In: Watson J, edito. Assessing and measuing caing in nusing and health sciences. 2nd ed. New Yok, NY: Spinge Publishing; p Wold Health Oganization. Pocess of tanslation and adaptation of instuments [Intenet]. Geneva, CH: Autho; 2012 [cited 2012 May 20]. Available fom: Lynn MR. Detemination and quantification of content validity. Nusing Reseach. 1986;35(6): Yun YH, Pak YS, Lee ES, Bang SM, Heo DS, Pak SY, et al. Validation of the Koean vesion of the EORTC QLQ-C30. Quality of Life Reseach. 2004;13(4): Fayes PM, Aaonson NK, Bjodal K, Goenvold M, Cuan D, Bottomley A. The EORTC QLQ-C30 scoing manual. 3d ed. Bussels, BE: Euopean Oganisation fo Reseach and Teatment of Cance; Kim GS. Analysis stuctual equation modeling. Seoul: Hannaae Publishing Co.; Hai JF, J., Black WC, Babin BJ, Andeson RE. Multivaiate data analysis. 7th ed. Uppe Saddle Rive, NJ: Peason Pentice Hall; p Fayes PM, Machin D. Quality of life: The assessment, analysis and epoting of patient-epoted outcomes. 3d ed. Chicheste, UK: John Wiley & Sons; p Steige JH. Tests fo compaing elements of a coelation matix.

12 132 So, Hyang Sook Chae, Myeong Jeong Kim, Hye Young Psychological Bulletin. 1980;87(2): Tewee CB, Bot SD, de Boe MR, van de Windt DA, Knol DL, Dekke J, et al. Quality citeia wee poposed fo measuement popeties of health status questionnaies. Jounal of Clinical Epidemiology. 2007;60(1): Kline RB. Pinciples and pactice of stuctual equation modeling. 3d ed. New Yok, NY: Guilfod Pess; p Kaise G. Phase-space appoach to elativistic quantum mechanics. III. Quantization, elativity, localization and gauge feedom. Jounal of Mathematical Physics. 2016;22(4): Wae JE, J., Gandek B. Methods fo testing data quality, scaling assumptions, and eliability: The IQOLA poject appoach. Intenational quality of life assessment. Jounal of Clinical Epidemiology. 1998;51(11): Nunnally JC, Benstein IH. Psychometic theoy. 3d ed. New Yok, NY: McGaw-Hill; p Pak HA. Poblems and issues in developing measuement scales in nusing. Jounal of Nusing Quey. 2005;14(1):