Design and sample
In this cross-sectional study, we recruited HNC patients using convenience sampling at the outpatient radiation department of a hospital in northern Taiwan from March 2020 to April 2022. The inclusion criteria were: (1) 20 years of age or older; (2) definitive histopathological diagnosis of HNC; (3) having completed treatment; (4) able to speak Mandarin or Taiwanese; and (5) agreement to join the study after explanation of research aims. Considering the heterogeneous modalities of nasopharyngeal, laryngeal, and parotid cancer, patients with these conditions were excluded from this study.
Ethical considerations
All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the University of Wisconsin Health Sciences Institutional Review Board (IRB approval104-8655B) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All participants provided written informed consent before data collection.
Measures
Body Image Scale (BIS)
Patients’ perceived distress regarding body image was measured using the Body Image Scale (BIS), developed by Hopwood et al. [19] This 10-item questionnaire covers two domains: perceived attractiveness and body appearance dissatisfaction. Each item is scored using a 4-point Likert scale, ranging from 0 (not at all) to 3 (very much), and a higher total score indicates greater symptoms or distress about body image [19–20]. A study showed satisfactory psychometric properties for the Chinese BIS [21]. The Cronbach’s α for the BIS in this study was 0.93.
Hospital Anxiety and Depression Scale–Depression Subscale (HADS–Depression Subscale)
The Hospital Anxiety and Depression Scale–Depression Subscale (HADS–Depression Subscale) was used to assess depression. It consists of 7 items and is scored on a Likert-type scale ranging from 0 to 3, with higher scores indicating more depression [22]. The cutoffs for the HADS–Depression Subscale were: 0–7, no depression; 8–10, borderline depression; and 11–21, depression [22]. We used the Chinese version of the HADS–Depression Subscale, which has acceptable reliability and validity [23]. In this study, the Cronbach’s α value was 0.92.
University of Washington Quality of Life Scale (UW-QOL)
Physical function and social-emotional function were measured using the University of Washington Quality of Life Scale (UW-QOL) version 4.0, developed by Rogers et al. [24] and originally described by Hassan and Weymuller [25]. The UW-QOL consists of 12 items measuring two domains: physical function (6 items) and psychosocial function (6 items). A study showed satisfactory psychometric properties for the Chinese UW-QOL [26]. In our study, the Cronbach’s α value for the UW-QOL was 0.90.
Shame and Stigma Scale (SSS)
Level of stigma was assessed using the SSS, developed by Kissane et al. [27] Its 20 items assess four subscales of SSS: shame with appearance (8 items), sense of stigma (6 items), regret (3 items), and speech and social concerns (3 items). Answers are provided for each item using a 5-point Likert scale ranging from 0 (never) to 4 (all the time). Summed scores are converted into a 0-100 scale for each subscale and for total scores. Higher scores indicate greater stigma [27]. The SSS was translated into Chinese, and a previous study reported satisfactory psychometric properties [28]. In the present study, the Cronbach’s α for the SSS was 0.93.
Karnofsky Performance Status (KPS)
The Karnofsky Performance Status (KPS) index is commonly used to assess performance status [29]. The KPS is a single item with an 11-point score ranging from100% (normal function) to 0% (death) [29].
Demographic and disease-related characteristics form
A form was used to collect demographic and disease-related characteristics. Patient-related characteristics included age, sex, occupation status, marital status, education level, smoking status, betel quid chewing status, and alcohol drinking status. Disease-related characteristics included tumor site, cancer stage, medical treatment, and time since treatment completion.
Statistical analysis
Descriptive statistics were used to summarize the distribution of demographic and disease-related characteristics as well as body image, depression, physical function, psychosocial function, and stigma levels (including subscales). Pearson’s product-moment coefficient was used to examine the relationships between stigma (dependent variable) and selected independent variables based on literature review (age, time since treatment completion [year], work status [no vs. yes], body image [BIS], depression [HADS-Depression Subscale], physical function [UW-QOL], and psychosocial function [UW-QOL]). The factors associated with stigma were determine using multiple regression analysis. The significant variables were found using Pearson’s product-moment coefficient analysis for independent variables in multiple regression. All calculations were made using SPSS for Windows, version 26.0 (IBM Corp., Armonk, NY, USA).