The research was led by first and corresponding author Vaia Pappa of the Aristotle University of Thessaloniki, working alongside co-authors Diomidis Antoniadis, Konstantinos Fountoulakis and Nikitas Arnaoutoglou from the same institution. Their starting point was a practical gap: although the CASS was originally developed to measure several distinct dimensions of cancer stigma, including avoidance, blame, policy opposition, personal responsibility, financial discrimination and perceptions of cancer severity, it had never been validated in Greek. Without a psychometrically sound Greek adaptation, researchers in Greece could not systematically assess how stigmatizing attitudes toward cancer are distributed in the population, how they vary across groups, or whether anti-stigma programs are actually changing minds. The new study was designed to close that gap and, in doing so, to test a broader theoretical idea: that stigma toward different illnesses may share common psychological roots.

To adapt the instruments for Greek participants, the team used a standardized forward-backward translation process involving independent bilingual experts and a separate back-translator. This approach, considered standard practice in cross-cultural scale validation, helps ensure that translated items preserve the original meaning rather than merely the original wording. Once the Greek versions were finalized, the researchers assessed internal consistency, construct validity and convergent validity using a battery of statistical techniques: Cronbach’s alpha for reliability, exploratory factor analysis for structural validity, Spearman correlations and regression analysis for convergent relationships, and receiver operating characteristic analysis, commonly abbreviated as ROC, for discriminatory performance.

The study sample consisted of 176 undergraduate, postgraduate and doctoral students recruited in Thessaloniki through convenience sampling. Participants had a mean age of 23.5 years, and 60.8 percent were women. Importantly for the study’s aims, approximately 39.8 percent reported a personal or family history of cancer, while 35.2 percent reported a personal or family history of mental illness. Each participant completed both the Greek CASS and the Community Attitudes toward the Mentally Ill scale, known as CAMI, allowing the researchers to examine whether attitudes toward cancer were associated with broader forms of health-related stigma rather than existing in isolation.

The psychometric results were encouraging. The Greek CASS demonstrated high overall internal consistency, with a Cronbach’s alpha of 0.89, a value well above the conventional threshold of 0.70 that researchers typically use to indicate acceptable reliability. Reliability across the individual subscales ranged from 0.72 to 0.86, suggesting that each dimension of the scale held together coherently in the Greek context. Exploratory factor analysis generally supported the scale’s original multidimensional structure, with most items loading onto their theoretically expected factors. Taken together, these findings provide evidence for the structural coherence and construct validity of the Greek version, meaning that the instrument appears to measure the same underlying dimensions of cancer stigma in Greek speakers that it measures in the populations where it was originally developed.

Perhaps the most conceptually striking findings emerged from the comparison with mental illness attitudes. Cancer-related stigma showed moderate to strong positive correlations with the CAMI dimensions of authoritarianism and social restrictiveness, with Spearman correlation coefficients ranging from 0.42 to 0.57. In practical terms, participants who endorsed authoritarian or socially restrictive views about people with mental illness also tended to endorse stigmatizing views about cancer. The authors interpret these relationships as evidence that different forms of health-related stigma may share underlying mechanisms involving fear, stereotyping, blame and social distancing. As the researchers state, the present findings further support the conceptualization of stigma as a generalized psychosocial construct operating across different health conditions, rather than a set of illness-specific attitudes that must be studied entirely separately.

Not every statistical result was equally strong, however, and the authors are candid about this. The regression model was not statistically significant and explained only 9.6 percent of the variance in cancer stigma scores. The ROC analyses showed limited to moderate discriminatory ability across most dimensions, with two CAMI dimensions performing acceptably: Authoritarianism achieved an area under the curve, or AUC, of 0.770, while Community Mental Health Ideology reached an AUC of 0.780. These values indicate moderate discrimination, above the chance level of 0.500 but far from perfect classification. The authors argue that such results reinforce the view that stigma is better understood as a complex, multidimensional construct than as a simple binary characteristic that people either possess or lack.

Demographic patterns added further nuance. Younger participants tended to report higher cancer-related stigma, while participants with personal or family experience of illness showed lower stigma levels. The authors suggest that familiarity with serious illness may reduce negative stereotypes and encourage more empathetic attitudes, a pattern consistent with established theories proposing that interpersonal contact can reduce stigma. The Greek cultural context may also shape how cancer stigma is expressed. The authors discuss the importance of family-centered approaches to illness, communication practices and religious or fatalistic beliefs. While family ties and spiritual beliefs can provide important sources of support for patients, certain patterns of silence or fatalistic interpretation may simultaneously contribute to fear, avoidance or reluctance to openly discuss a cancer diagnosis. These observations argue for culturally sensitive approaches to stigma reduction rather than assuming that attitudes toward cancer operate identically across populations.

The validated Greek CASS now offers researchers and clinicians a practical instrument for assessing cancer-related stigma in both community and clinical settings. The authors suggest that identifying stigmatizing attitudes can help inform psychoeducational programs, supportive counseling and public-awareness initiatives, and that the observed relationship between cancer and mental illness stigma points toward integrated approaches that address health-related stigma more broadly rather than condition by condition. The findings, they note, highlight the persistence of stigma and underscore the importance of culturally tailored interventions targeting both cancer-related and mental illness stigma.

Important limitations temper these conclusions. The study relied primarily on a young, highly educated university-based sample, which limits generalizability to older adults, oncology patients and people from more diverse socioeconomic backgrounds. Its cross-sectional design prevents causal conclusions about the relationships observed, and variance-explained indices from the exploratory factor analysis were not retained in the archived statistical outputs, limiting the completeness of the construct-validity evaluation. Future validation in larger and more diverse populations, including cancer patients, caregivers, healthcare professionals and rural communities, will therefore be essential. Even so, the study supports the Greek version of the CASS as a reliable and valid tool for assessing cancer-related stigma and establishes a foundation for broader studies of cancer stigma in Greece and for the development and evaluation of culturally informed anti-stigma interventions.

Subject of Research: Validation of the Greek Cancer Stigma Scale and its relationship to mental illness stigma attitudes

Article Title: Greek version of cancer stigma scale validated for assessing cancer-related stigma

Article References: Greek version of cancer stigma scale validated for assessing cancer-related stigma. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: cancer stigma, Cancer Stigma Scale, CASS, psychometric validation, Greece, mental illness stigma, CAMI, psycho-oncology, cross-cultural adaptation, Cronbach's alpha, social stigma, Aristotle University of Thessaloniki