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The effects of physical functioning and public stigma on psychological distress as mediated by cognitive and social factors among Korean survivors of childhood cancer

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The effects of physical functioning and public stigma on psychological distress as mediated by cognitive and social factors among Korean survivors of childhood cancer

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Content THE EFFECTS OF PHYSICAL FUNCTIONING AND PUBLIC STIGMA ON
PSYCHOLOGICAL DISTRESS AS MEDIATED BY COGNITIVE AND SOCIAL
FACTORS AMONG KOREAN SURVIVORS OF CHILDHOOD CANCER

by

Min Ah Kim

______________________________________________________________________________

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

August 2012

Copyright 2012 Min Ah Kim

ii
DEDICATION
This dissertation is dedicated to my former mentor Dr. Ick Seop Lee and my good
friend, Jennifer Paek. Dr. Lee inspired me to continue to be greater than I believed I could
ever be. Jennifer stood up for me through thick and thin and still inspires me today. I
couldn’t have completed the doctoral program without her. They will be greatly missed,
but will always be remembered in my heart.
This dissertation is especially dedicated to all adolescent and young adult cancer
patients, survivors, and their family members.

iii
ACKNOWLEDGEMENTS
I would like to express my sincere appreciation to my mentor Dr. Ann Marie
Yamada and my dissertation committee, Dr. John Brekke and Dr. Chih-Ping Chou for
their guidance and support. I especially thank Dr. Ann Marie Yamada for chairing my
dissertation committee and believing in me during my four years at USC. Without Dr.
Jaehee Yi who listened to me when I needed to talk, I wouldn’t have had peace of mind
during a very difficult time. I would also like to thank my husband who provided me with
unending support and encouragement over 10 years. Finally, and most importantly, I
would like to thank my family for the support that they have given me and the sacrifices
they have made to give me a second chance on life. I love them more than I could ever
describe in words.

iv
TABLE OF CONTENTS
DEDICATION .................................................................................................................... ii
ACKNOWLEDGEMENTS ............................................................................................... iii
LIST OF TABLES .............................................................................................................. v
LIST OF FIGURES ........................................................................................................... vi
ABSTRACT ...................................................................................................................... vii
CHAPTER 1: INTRODUCTION ....................................................................................... 1
CHAPTER 2: LITERATURE REVIEW ............................................................................ 4
Physical Functioning and Pathways to Psychological Distress .............................. 5
Public Stigma Associated with Cancer and Pathways to
Psychological Distress ............................................................................................ 7
Gender Differences in Relation to Psychological Distress ................................... 14
Conceptual Model ................................................................................................. 16
CHAPTER 3: RESEARCH AIMS ................................................................................... 17
CHAPTER 4: METHODS ................................................................................................ 23
Data Source ........................................................................................................... 23
Participants and Procedures .................................................................................. 23
Measures ............................................................................................................... 24
Data Analyses ....................................................................................................... 32
CHAPTER 5: RESULTS .................................................................................................. 44
Sample Characteristics .......................................................................................... 44
Results for Research Aim 1 .................................................................................. 48
Results for Research Aim 2 .................................................................................. 57
Results for Research Aim 3 .................................................................................. 63
Results for Research Aim 4 .................................................................................. 70
CHAPTER 6: DISCUSSION ............................................................................................ 76
CHAPTER 7: CONCLUSION ......................................................................................... 92
REFERENCES ................................................................................................................. 93

v
LIST OF TABLES
Table 1: Sociodemographic Characteristics of the Participants........................................ 45
Table 2: Cancer-Related Characteristics of the Participants ............................................. 47
Table 3: Comparison of the Prevalence of Psychological Distress between
Survivors and the Norm Population .................................................................... 49
Table 4: Sociodemographic Characteristics of Survivors by Prevalence of
Psychological Distress ........................................................................................ 51
Table 5: Cancer-Related Characteristics of Survivors by Prevalence of
Psychological Distress ........................................................................................ 54
Table 6: Differences in the Study Variables by Prevalence of
Psychological Distress ........................................................................................ 56

Table 7: Sociodemographic Correlates of Psychological Distress ................................... 59
Table 8: Cancer-Related Correlates of Psychological Distress ....................................... 61
Table 9: Multivariate Logisitic Regression Analysis of Psychological Distress .............. 62
Table 10: Bivariate Correlations among Observed Variables .......................................... 64
Table 11: Factor Loadings for the Measurement Model................................................... 65
Table 12: Fit Indices for Hypothesized Structural Model................................................. 66
Table 13: Indirect Effect Estimates through Self-Stigma, Self-Disclosure,
and Social Support Availability ........................................................................ 69
Table 14: Descriptive Statistics for Main Study Variables by Gender ............................. 71
Table 15: Fit Indices for Hypothesized Structural Models Across Gender ...................... 72
Table 16: Indirect Effect Estimates through Self-Stigma, Self-Disclosure,
and Social Support Availability for Male Survivors ......................................... 74
Table 17: Indirect Effect Estimates through Self-Stigma, Self-Disclosure,
and Social Support Availability for Female Survivors ..................................... 75

vi
LIST OF FIGURES
Figure 1: Conceptual Model of the Impact of Physical Functioning, Stigma,
Self-Disclosure, and Social SupportAvailability on Psychological Distress ..... 16

Figure 2: Structural Model for Mediation of Perceived Physical Functioning
and Perceived Public Stigma Effects on Psychological Distress ...................... 67

vii
ABSTRACT
The overall purpose of this dissertation is to examine cognitive and social
mediators of psychological distress in Korean childhood cancer survivors. The four
specific research aims are (1) to examine the overall prevalence of psychological distress
and to compare the profile of cancer survivors with and without significant levels of
psychological distress, (2) to examine perceived physical functioning and perceived
public stigma as potential risk factors for psychological distress, taking into account
possible sociodemographic and cancer-related correlates, (3) to test a model of the effects
of perceived physical functioning and perceived public stigma on psychological distress
as mediated through three cognitive and social factors (self-stigma, cancer disclosure, and
social support), and (4) to examine gender differences within the mediated effects of
perceived physical functioning and perceived public stigma on psychological distress.
Participants consisted of 223 cancer survivors (i.e., had completed cancer
treatment) diagnosed before the age of 19 years and currently residing in the community
in Korea. The proportion of the male and female participants was similar, and their mean
age was 21.9 years, ranging from 15 to 38 years. Participants were recruited through
Korean advocacy foundations and support groups for adolescent and young adult
survivors of childhood cancer. Structured questionnaires were collected from June 2010
to November 2010 either by mail or email. The overall goodness of the structural model
was tested and then total and specific indirect effects were tested by using bootstrap
procedures in Mplus 6.12.
The primary results showed an overall prevalence rate of approximately 20% for

viii
psychological distress. Significant levels of psychological distress were related to older
age, unstable economic status and longer time since diagnosis. Perceived poorer physical
functioning and higher levels of perceived public stigma were strong risk factors for
psychological distress, while controlling for age, economic status, cancer type, and time
since diagnosis. There was a significant mediated effect of perceived physical functioning
on psychological distress through social support availability. There was also a significant
mediated effect of perceived public stigma on psychological distress through internalized
shame (self-stigma) or social support availability, or through a chain of two mediators-
self-disclosure and internalized shame. The mediated effect of perceived public stigma on
psychological distress differed by gender.
This study offers evidence to support the important roles of cognitive and social
factors in mediating the relationships between perceived physical functioning, perceived
public stigma, and psychological distress among cancer survivors. A greater
understanding of the factors influencing the levels of psychological well-being could
potentially help social workers and other professionals identify childhood cancer
survivors in greater needs of psychosocial services and provide them with appropriate
resources and interventions.

1
CHAPTER 1: INTRODUCTION
The five-year survival rate for childhood cancer is approaching 80% in the United
States (Reis et al., 2003). Although childhood cancer survival rates in other nations are
slightly lower than in the United States, the number of survivors of childhood cancer has
rapidly increased around the world. However, there continues to be a persistent lack of
understanding about the psychosocial aspects of cancer survival post-treatment.
Cancer diagnosis is often conceptualized as a traumatic event that may be
followed by long-term psychological effects (Stuber, Kazak, Meeske, & Barakat, 1998).
Although the majority of long-term survivors of childhood cancer seem to report good
psychological health (Newby, Brown, Pawletko, Gold, & Whitt, 2000; Recklitis et al.,
2006) or psychologically successful adaptation (Langeveld, Stam, Grootenhuis, & Last,
2002; Zebrack & Chesler, 2002; Zebrack et al., 2007), some survivors consistently report
psychological difficulties (Brown, Madan-Swain, & Lambert, 2003; Hobbie et al., 2000;
Hudson et al., 2003; Rourke, Hobbie, Schwartz, & Kazak, 2007; Stam, Grootenhuis, &
Last, 2005; Wiener et al., 2006; Zebrack et al., 2002).
When the survivors become adolescents and young adults (AYA) transitioning
from childhood to adulthood, they are likely to face unique challenges resulting from
their cancer history. For example, AYA survivors report a wide range of late effects, such
as numbness, memory and attention deficits, and fatigue (Berg, Neufeld, Harvey, Downes,
& Hayashi, 2009), or cancer-related infertility (Stein, Syrjala, & Andrykowski, 2008) that
emerge long after childhood cancer treatment ends. These challenges might adversely

2
affect their quality of life during young adulthood (Oeffinger et al., 2006; Richardson,
Nelson, & Meeske, 1999).
To further understand the unique vulnerability of AYA childhood cancer
survivors, a growing number of studies have examined predictors of psychological
outcomes. Two salient risk factors of psychological distress that have been identified are
perceived physical functioning and perceived public stigma (Gonzalez & Jacobsen, 2011;
Molassiotis & Milligan, 1996). Perceptions of limited physical functioning are often
expressed by cancer survivors mainly due to the intense nature of cancer treatment. It
follows that survivors perceiving themselves as limited in their physical functioning are
less able to conceal their impaired physical functioning and thereby are more likely to
perceive public stigma towards cancer (Fife & Wright, 2000). However, the mechanisms
by which these salient risk factors affect long-term psychological distress have been
understudied. Gaining a better understanding of these mechanisms can assist in
determining more specific risk and protective factors as well as in development of
specific interventions for psychological distress experienced by AYA cancer survivors.
Given racial and ethnic disparities in survival and death rates for most cancers
(Albain, Unger, Crowley, Coltman Jr, & Hershman, 2009; Edward et al., 2005), there
appears to be ethnic variability in the quality of life experiences of survivors (Ashing-
Giwa et al., 2004). However, the majority of the studies examining quality of life for
childhood cancer survivors have been conducted in the United States, with little attention
paid to specific ethnic groups. Only a handful of studies have been conducted in Europe
(see Apajasalo et al., 1996; Evans & Radford, 1995; Veenstra, Sprangers, van der Eyken,

3
& Taminiau, 2000 and Asia (Ho, Chen, & Ho, 2004; Schroevers & Teo, 2008), making it
difficult to generalize the findings to cross-national groups of survivors. Given that Korea
is one of the countries where survival rates have been rapidly increasing in the last decade
(Korean National Cancer Institute, 2011), this study expands the body of literature on the
quality of life of childhood cancer survivors by examining the psychological health of an
understudied group of long-term survivors. Only by studying different groups can we
better understand the psychological well-being of cancer survivors in diverse contexts
and make current knowledge applicable to those in other countries.
The purpose of this dissertation is to examine the overall prevalence of
psychological distress and the characteristics of AYA childhood cancer survivors who are
at risk of psychological distress. This work is significant in that it contributes to
identifying characteristics of clinically distressed cancer survivors who may be in great
need of psychosocial services. This dissertation further investigates the potential
determinants of psychological distress in general, and the mediating factors affecting
psychological distress in particular for AYA childhood cancer survivors. The research
offers evidence to support the important roles of cognitive and social mediators for
interventions in cancer survivor population. Expanding the sample of survivors beyond
the US allows for exploration of the universality of interventions. Throughout this
dissertation, the term adolescent and young adult (AYA) is used on the National Cancer
Institute’s definition (2006) of cancer survivors as between the ages of 15 and 39 years
old.

4
CHAPTER 2: LITERATURE REVIEW
Based on an existing theoretical framework, the following section reviews two
salient risk factors (perceived physical functioning and perceived public stigma) in
relation to psychological distress among adolescent and young adult (AYA) cancer
survivors. More specifically, it reviews how these two salient factors impact
psychological distress through three possible mediating factors: self-stigma related to
being cancer survivors; self-disclosure about cancer experiences; and perceived
availability of social support. Gender differences in factors associated with psychological
distress are also examined.
As introduced above, cancer survivors are shown to be at high-risk for
psychological problems due to the traumatic experience of the cancer diagnosis and
resulting treatment. Increasingly there are empirical findings of potential risk factors for
psychological distress in AYA childhood cancer survivors. Previous research has shown
that sociodemographic characteristics, such as gender, educational level, income
attainment, marital status and employment, and cancer-related characteristics, such as
cancer type, age at diagnosis, and medical treatment are associated with psychological
distress reported by childhood cancer survivors (Kazak et al., 2010; Langeveld,
Grootenhuis, Voute, De Haan, & Van Den Bos., 2004; Zebrack et al., 2002; 2004; 2007;
Zeltzer et al., 1997; 2008; 2009). Such factors may explain different levels of
psychological distress in cancer survivors. However, little is known about physical
functioning and public stigma perceived by cancer survivors and how these factors affect
their psychological distress. In this dissertation, specific emphasis was given to the

5
mediating processes of three cognitive and social factors (i.e., self-stigma, self-disclosure,
and social support availability) that may explain the circumstances under which
mediating factors develop and why many cancer survivors become distressed. Careful
consideration of such mechanisms may clarify our understanding of psychological
distress in cancer survivors.
Physical Functioning and Pathways to Psychological Distress
In addition to sociodemographic and cancer-related factors, physical functioning
has been shown to be a salient risk factor for psychological health (Zebrack et al., 2004;
2007; Zeltzer et al., 2008) and psychological adjustment (Elkin, Phipps, Mulhern, &
Fairclough, 1997) among childhood cancer survivors. Childhood cancer survivors often
report substantial physical long-term effects resulting from treatment (Meister &
Meadows, 1993; Mulrooney et al., 2008; Oeffinger, Eshelman, Tomlinson, Buchanan, &
Foster, 2000; Schwartz, Hobbie, Constine, & Ruccione, 1994). They are more likely to
report adverse general health, functional impairment (Hudson et al., 2003; Servitzoglou,
Papadatou, Tsiantis, & Vasilatou-Kosmidis, 2009) and lower levels of physical well-
being (McDougall & Tsonis, 2009; Speechley, Barrera, Shaw, Morrison, & Maunsell,
2006) than comparison samples.
There is a substantial body of health research that finds an impact of physical
health on psychological distress (Farmer &Ferraro, 1997; Tessler & Mechanic, 1978).
Self-appraisal of physical health is especially crucial in predicting psychological well-
being as these perceptions explain comprehensive physical well-being better than
objective evaluation (Tessler & Mechanic, 1978).

6
The diathesis-stress model (Weissman & Markowitz, 1998), often applied in
pediatric illness studies, posits that individuals have a social, cognitive, and biological
vulnerability to developing psychological symptoms following a major stressful event,
such as cancer diagnosis and treatment (Hilsman & Garber, 1995). This model may
explain that survivors with limited physical functioning are likely to be vulnerable to
psychological distress. In this model, the role of social support appears to be especially
important in buffering vulnerability to stressors. The following section examines the
mediating effect of social support on the relationship between physical functioning and
psychological distress in cancer survivors.
Mediated effect of physical functioning on psychological distress through
social support. There are inconsistent findings related to the levels of social support
reported by cancer survivors. In some studies, adolescent cancer survivors reported
greater support from family (Brown et al., 2003; Haluska, Jessee, & Nagy, 2002),
whereas similar levels of support were received compared to healthy norms in other
studies (Manne & Miller, 1998; Stern, Norman, & Zevon, 1993). Although support
ranged in degree and sources, it is evident that social support plays an important role in
the lives of cancer survivors (for a review, see Decker, 2007).
One possible explanation for such inconsistent findings may be related to the
impact of perceived physical functioning. Perceived physical functioning is often linked
to perceived social support in individuals with illness as they may lose their usual roles
and responsibilities (Bloom & Kessler, 1994). The social activity hypothesis proposes
that individuals with limited physical functioning may avoid social activities and miss

7
opportunities to exchange social support (Bloom & Spiegel, 1984). Such decreased
involvement in social activities may lead to the loss of valued identities and the
perception of decreased social support (Bloom, 1982; Thoits, 1982). Thus, it is plausible
that cancer survivors’ perceived physical functioning may positively relate to the level of
social support availability.
Cohen and Wills (1985) have articulated a stress buffering hypothesis for social
support. For those experiencing cancer, the role of social support is especially crucial as a
coping resource (Thoits, 1995) as well as a protective factor against stress (Wortman,
1984) because it mitigates negative cancer experiences. Specifically, social support was
found to buffer the negative effects of symptoms (Manning-Walsh, 2005) and physical
functioning (Carpenter, Fowler, Maxwell, & Andersen, 2010) on their quality of life and
psychological adjustment in survivors of different types of cancer. Similarly, perceived
availability of support has been shown to protect against psychological distress (Cohen &
Hoberman, 1983; Wilcox, 1981). A negative association between perceived social
support and psychological distress was consistent both in Korean American and native
Korean cancer survivors (Lim & Zebrack, 2008). Thus, it is hypothesized that social
support has a mediating effect that may alter the relationship between perceived physical
functioning and psychological distress in Korean AYA cancer survivors.
Public Stigma Associated with Cancer and Pathways to Psychological Distress
Stigma is often reported as the source of stress among cancer survivors and is
negatively associated with functional health (Fife & Wright, 2000). Cancer and its
treatment leave visible physical signs such as hair loss or scars as well as invisible marks

8
(Hamilton & Zebrack, 2011). Stigma, referred to as a “mark” (Goffman, 1963), is defined
as “an attribute or characteristic that conveys a social identity that is devalued in a
particular social context” (Crocker, Major, & Steele, 1998, p. 505). Stigma operates at
two different levels: public stigma and self-stigma (Corrigan & Larson, 2008). Public
stigma is expressed through negative beliefs, reactions, and behaviors toward discredited
and devalued individuals (Corrigan & Larson, 2008).
Researchers have long been interested in the negative role of public stigma
attached to illness. Understanding perceptions of public stigma associated with health is
particularly critical in addressing quality of life issues for cancer survivors as stigma is
known to contribute to physical and psychological difficulties (Major & O’Brien, 2005).
A lack of knowledge and understanding about cancer and fear of the illness results in
stigmatizing attitudes towards cancer patients and survivors (Ablon, 2002; Rosman,
2004). Fear about cancer leads individuals to attribute the disease to undesirable personal
characteristics, therefore, negative consequences of cancer are often overestimated in
society (Bloom & Kessler, 1994). Public stigma associated with cancer leads cancer
survivors to experience discrimination in a wide range of contexts due to the
misperception about cancer associated with fatality and contagiousness (Baker, Curbow,
& Wingard, 1991; Brown & Tai-Seale, 1992; Loescher, Clark, Atwood, Leigh, & Lamb,
1990).
A substantial body of evidence suggests there is a positive association between
public stigma and psychological distress in the cancer population (Else-Quest, LoConte,
Schiller, & Hyde, 2009; Gonzalez & Jacobsen, 2011; Phelan et al., 2011), highlighting

9
the significance of stigma as a stressor for individuals with cancer. An effort to
understand the mechanisms underlying stigma is, however, still ongoing as the stigma of
cancer is greatly embedded in its cultural context (Ashing-Giwa et al., 2004). Survivors
of childhood cancer in Korea are particularly vulnerable to stigma as cancer is thought to
be the most fatal illness and fewer educational programs about cancer are provided in
Korea (Kim & Yi, 2012). In this dissertation, the conceptualization of stigma was used
based on modified labeling theory (Link, Cullen, Struening, Shorout, & Dohrenwend,
1989) which helps one to understand how stigmatization impacts overall psychological
well-being. Based on this theoretical model, this dissertation investigates the direct as
well as indirect effects of public stigma on psychological distress. Importantly, potential
mediating processes that allow public stigma to affect psychological distress were
specified through (1) self-stigma, (2) self-disclosure, and (3) social support availability.
Examining these mediating processes may help clarify the conditions under which factors
buffer or exacerbate the negative effects of public stigma and which factors are relevant
in a given stigmatized situation.
Mediated effect of public stigma on psychological distress through self-
stigma. The dimensions of stigma should be specified in order to clarify the unique and
common influences of stigma (Fife & Wright, 2000). Referred to as self-stigma,
stigmatized individuals internalize negative perceptions about themselves (Holmes &
River, 1998). Consistent with modified labeling theory (Link et al., 1989), negative social
attitudes (public stigma) towards cancer may influence self-stigma (e.g., feelings of self-
blame or shame) related to being cancer survivors. This self-stigma, in turn, leads to

10
negative psychological outcomes (Berger, Ferrans, & Lashley, 2001; Quinn & Chaudoir,
2009). Similar to the effects of public stigma, self-stigma contributes to depressive
symptoms (Lee, Kochman, & Sikkema, 2002; Simbayia et al., 2007), and to anxiety and
hopelessness (Lee et al., 2002).
A growing body of research shows the mediating role of self-stigma. Vogel,
Wade, and Hackler (2007) supported the mediating effect of self-stigma on the
relationship between perceived public stigma and help-seeking behaviors, indicating
greater impact of self-stigma than perceived public stigma in such relationships. Similarly,
one’s psychological distress may have a strong association with self-stigma as self-stigma
can directly lead to loss of self-esteem (Link, Cullen, Frank, & Wozniak, 1987). However,
the role of self-stigma has not been fully understood in cancer survivors. Therefore, this
dissertation suggests that perceived public stigma may indirectly affect psychological
distress through one’s internalized degree of perceived stigma (self-stigma) in childhood
cancer survivors.
Mediated effect of public stigma on psychological distress through self-
disclosure. Disclosure about a stigmatized condition is an important issue for a variety of
health conditions. Self-disclosure refers to the act of voluntarily providing previously
unknown information to another (Omarzo, 2000; Rosenfeld, 1979), the ‘process of
making the self known to others’ (Jourard & Lasakow, 1958, p. 91). Public stigma
towards cancer patients and survivors often prevent them from disclosing their cancer
history and sharing their cancer experiences. Modified labeling theory (Link et al., 1989)
explains that stigmatized individuals may choose to conceal their medical or treatment

11
history from others (Goffman, 1963). In contrast to those with physical disabilities,
individuals with invisible stigma such as history of cancer are likely to maintain secrecy
about their experience in order to avoid discrimination (Goffman, 1963; Joachim &
Acorns, 2000; Jones et al., 1984). Enskar, Carlsson, Golsater, and Hamrin (1997) found
that adolescent cancer survivors did not want to share their cancer experience with their
parents. Similarly, Ashing-Giwa et al (2004) found that cancer survivors from diverse
ethnic groups did not openly discuss cancer in the family during their childhood,
indicating that shame regarding cancer is common in certain cultures.
Although the mechanism by which disclosure operates in relation to
psychological distress has not been fully understood (for a review, see Pachankis, 2007),
being open about a concealable stigma appears to mitigate the negative effects of public
stigma on psychological well-being (Fisher & Chaudoir, 2010). Pachankis’s (2007)
cognitive-affective-behavioral model posits that having a stigmatized condition that is
concealed can result in increased psychological distress through cognitive, affective, and
behavioral processing. In terms of cognitive consequences, individuals avoiding
disclosure are consistently vigilant in social interactions in order to maintain secrecy
(Smart & Wegner, 2000). They also experience negative affective states, such as guilt
and shame when hiding stigma. For example, they may worry about when to disclose
their cancer history and how they will communicate it to others (Frable, Blackstone, &
Sherbaum, 1990). Such negative cognitive and affective processing leads individuals to
avoid social situations, which negatively impacts psychological well-being (Pachankis,
2007). Several studies report that withdrawal or avoidance in discussing the cancer

12
experience has negative consequences for cancer patients’ and survivors’ psychological
health (Gotcher, 1995; Mallinger, Griggs, & Shields, 2006; Park, Bharadwaj, & Blank,
2011). For example, withdrawal by patients or partners from each other is associated with
higher levels of distress (Manne et al., 2006). Sharing information among family
members is associated with higher rates of psychological well-being (Walsh-Burke,
1992). Beyond informational disclosure, emotional expressions about their experiences
can also buffer the adverse effects of distress among cancer patients (Zakowski,
Valdimarsdottir, & Bovbjerg, 2001; Zakowski, Ramati, Morton, Johnson, & Flanigan,
2004). Thus, this dissertation research examines whether self-disclosure may mediate the
effects of public stigma on psychological distress among cancer survivors.
Self-disclosure of a stigmatized condition can also buffer the negative effects of
public stigma on self-stigma, as it impacts an individual’s sense of identity and self-
esteem (Braithwaite, 1991; Charmaz, 1993; Goffman, 1963). When this stigma is shared,
individuals may experience rejection in employment, medical care and education, and
social isolation (Corrigan & Kleinlein, 2005; Herek, 1998). Although disclosing
stigmatizing conditions may result in such discrimination, individuals may not worry
about choosing to disclose and feel less internalized stigma (Corrigan & Larson, 2008).
While specific attention has been given to psychological issues related to the
patterns of disclosure and stigma in other illness populations, such as mental illness or
HIV/AIDS, scarce attention beyond the decision to disclose has been paid to the role of
self-disclosure in cancer populations. Understanding how self-disclosure of their stigma
operates in relation to public and self-stigma is crucial in understanding the long-term

13
effects of illness on psychological distress. Therefore, the dissertation examines
relationships between cancer-related stigma and the level of self-disclosure about cancer
experiences which may impact their self-stigma and psychological well-being.
Mediated effect of public stigma on psychological distress through social
support. One’s perception of social support appears to be important for the psychological
well-being of stigmatized individuals. Individuals with a concealable stigma may choose
to avoid close relationships or limit social interactions to those accepting of the
stigmatized condition due to fear of rejection (Goffman, 1963; Markowitz, 1998). For
example, cancer survivors may lose their supportive social networks due to stigma (Cobb
& Erbe, 1978). Since individuals with low self-esteem are less likely seek support
(Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruenet, 1986), those who feel
stigmatized may perceive lower availability of social support, thereby increasing
psychological distress (Mak et al., 2007). Evidence shows a negative association between
public stigma and perceived social support (Galvan, Davis, Banks, & Bing, 2008).
Consistent with the buffering hypothesis (Cohen & Wills, 1985), perceived social support
was shown to mediate the relationship between stigma and illness-related distress (Slade,
O’Neill, Simpson, & Lashen, 2007). Little is known, however, about the role of social
support in relation to public stigma and psychological distress among childhood cancer
survivors. Thus, this dissertation suggests that the effect of public stigma on
psychological distress may be mediated through social support availability.

14
Gender Differences in Factors Associated with Psychological Distress
Gender has shown to be a strong determinant of health outcomes in the general
population as well as for survivors of childhood cancer (for a review, see Armstrong,
Sklar, Hudson, & Robison, 2007). Evidence suggests that female survivors of childhood
cancer are likely to have a lower health-related quality of life compared to male survivors
(Langeveld et al., 2004; Shankar et al., 2005; Wu et al., 2007; Zebrack & Chesler, 2002;
Zebrack et al., 2002; Zeltzer et al., 1997; 2008). Although the causes that underlie these
gender differences are unknown, one reason may be differences in the impact of
cognitive and social factors on psychological distress. For example, researchers have long
been interested in gender differences in social support and it appears that women
experience more support than men during adolescence and adulthood (Rosario, Shinn,
Morch, & Huckabee, 1988; Soloman & Rothblum, 1986). In addition, having a larger
network was significantly associated with poorer psychological symptoms for female but
was not associated with psychological symptoms for male patients (Hanna et al., 2002).
To date, there is very little known about how stigma and self-disclosure impact
psychological distress in cancer survivors based on gender differences. Previous literature
based on other populations found that women are likely to report higher levels of stigma
and disclosure than men (Slade et al., 2007). Furthermore, a negative association between
stigma and disclosure has been found in males, but no association has been found in
females (Slade et al., 2007). In many studies of cancer populations, the effect of gender
was controlled for in studies of psychological distress, but apart from that, gender
differences have not featured highly in the research. This dissertation examines gender

15
differences in the mediating effects of cognitive and social factors on psychological
distress as a consequence of the cancer experience.
Conceptual Model
As reviewed above, self-stigma, self-disclosure, and perceived availability of
social support play significant roles in buffering or exacerbating the impact of perceived
physical functioning and perceived public stigma on one’s psychological distress. Based
on theoretical models and empirical studies discussed previously, this dissertation
presents a model (Figure 1) through which three cognitive and social factors mediate the
effects of perceived physical functioning and perceived public stigma on psychological
distress. The primary mediation model proposes that perceptions of physical functioning
and public stigma affect psychological distress directly as well as indirectly through self-
stigma, self-disclosure, and perceived availability of social support.

16

Figure 1. Conceptual Model of the Impact of Physical Functioning, Stigma, Self-
Disclosure, and Social Support Availability on Psychological Distress

Psychological
Distress
Perceived
Physical
Functioning
Self-Disclosure
Perceived
Social Support
Availability
Perceived
Public
Stigma

Self-Stigma

17
CHAPTER 3: RESEARCH AIMS
The overall purpose of this dissertation is to examine cognitive and social
mediators of psychological distress in adolescent and young adult (AYA) childhood
cancer survivors in Korea. The four specific research aims are: (1) to examine the overall
prevalence of psychological distress and compares the profile of cancer survivors with
and without significant levels of psychological distress, (2) to examine perceived physical
functioning and perceived public stigma as potential risk factors for psychological
distress, taking into account possible sociodemographic and cancer-related correlates, (3)
to test a model of the effects of perceived physical functioning and perceived public
stigma on psychological distress as mediated through three cognitive and social factors
(self-stigma, self-disclosure, and social support), and (4) to examine gender differences
within the mediated effects of perceived physical functioning and perceived public stigma
on psychological distress.

Research Aim 1: To examine the overall prevalence of psychological distress and to
compare the profile of AYA childhood cancer survivors with and
without significant levels of psychological distress

Examining the overall prevalence of psychological distress and characteristics of
AYA childhood cancer survivors with and without significant levels of psychological
distress is significant for developing an effective outreach strategy for hard-to-reach
populations. Consideration must be given to their needs regarding their psychological

18
well-being following a traumatic cancer diagnosis and treatment. Understanding the
profiles of cancer survivors with significant levels of psychological distress helps in the
development of appropriate interventions targeting those at high risk for psychological
distress. The following two specific questions address research Aim 1.

Research question 1a: How prevalent is psychological distress among AYA
childhood cancer survivors?

Research question 1b: To what extent do AYA childhood cancer survivors with
and without significant levels of psychological distress
differ in sociodemographic, cancer-related characteristics,
perceived physical functioning, perceived public stigma,
self-stigma, self-disclosure, and social support availability?

Research Aim 2: To examine perceived physical functioning and perceived public
stigma as potential risk factors for psychological distress, taking into
account possible sociodemographic and cancer-related correlates among
AYA childhood cancer survivors

This aim extends previous research by adding literature on risk factors of
psychological distress among AYA cancer survivors from diverse ethnic groups. Unlike
previous studies that have focused solely on demographics and medical characteristics,
this study further examines potential risk factors pertaining to perceived physical

19
functioning and perceived public stigma. Research Aim 2 is addressed by testing the
following three research hypotheses.

Hypothesis 2a: Sociodemographic characteristics will be associated with
significant levels of psychological distress.

Hypothesis 2b: Cancer-related characteristics will be associated with significant
levels of psychological distress.

Hypothesis 2c: Perceived physical functioning and perceived public stigma will
be associated with significant levels of psychological distress,
controlling for sociodemographic and cancer-related correlates.

Research Aim 3: To examine a model of the effects of perceived physical functioning
and perceived public stigma on psychological distress as mediated
through three cognitive and social factors (self-stigma, cancer
disclosure, and social support availability) in AYA childhood cancer
survivors

This aim not only helps apply the labeling theory and buffering hypotheses of
social support to cancer survivors but also support development of psychosocial
interventions targeting identifiable and modifiable cognitive and social factors for AYA
cancer survivors. Based on the proposed conceptual model that incorporates theories

20
related to stigma, self-disclosure, and social support, research Aim 3 posits the following
two research hypotheses.

Hypothesis 3a: Perceived better physical functioning will predict a lower level of
psychological distress, and this relationship will be mediated by
level of perceived social support availability.

This hypothesis examines the effects of perceived physical functioning on
psychological distress as mediated by social support availability. Specifically, it is
hypothesized that perceived physical functioning will be positively related to social
support availability and social support availability will, in turn, be negatively related to
psychological distress. The hypothesized relations are as follows: perceived physical
functioning → social support availability → psychological distress.

Hypothesis 3b: Higher level of perceived public stigma will predict greater levels
of psychological distress, and this relationship will be mediated by
the level of self-stigma, self-disclosure, and social support
availability.

In this hypothesis, self-stigma, self-disclosure, and social support availability
were proposed to mediate the relationship between perceived public stigma and
psychological distress. More specifically, four possible specific indirect paths between

21
perceived public stigma and psychological distress were hypothesized: (1) perceived
public stigma will be positively related to self-stigma and self-stigma will then be
positively related to psychological distress. The hypothesized relations are as follows:
perceived public stigma → self-stigma → psychological distress. (2) Perceived public
stigma will be negatively related to the levels of self-disclosure, and self-disclosure will
then be negatively related to psychological distress. The hypothesized relations are as
follows: perceived public stigma → self-disclosure → psychological distress. (3)
Perceived public stigma will be negatively related to levels of self-disclosure, which
negatively predict self-stigma, and self-stigma will then be positively related to
psychological distress. The hypothesized relations are as follows: perceived public stigma
→ self-disclosure → self-stigma → psychological distress. (4) Perceived public stigma
will be negatively related to social support availability and social support availability will
be negatively related to psychological distress. The hypothesized relations are as follows:
perceived public stigma → social support availability → psychological distress.

Research Aim 4: To examine gender differences within the mediated effects of
perceived physical functioning and perceived public stigma on
psychological distress through self-stigma, self-disclosure, and social
support availability among AYA childhood cancer survivors

Better understanding of gender differences within the mediated effects of
perceived physical functioning and perceived public stigma on psychological distress

22
(through cognitive and social mediators) can help with the development of appropriate
resources for cancer survivors. The focus of psychosocial interventions may need to be
adjusted based on gender. Research Aim 4 addresses the following two research
hypotheses.

Hypothesis 4a: The mediated effects of perceived physical functioning on
psychological distress through social support availability will be
different for male and female survivors.

Hypothesis 4b: The mediated effects of perceived public stigma on psychological
distress through self-stigma, self-disclosure and social support
availability will be different for male and female survivors.

23
CHAPTER 4: METHODS
Data Source
This dissertation was based on a Korean childhood cancer survivor sample from
research supported by the Korea Childhood Leukemia Foundation (KCLF). The study,
conducted by the author, was one of the first to examine Korean on adolescent and young
adult (AYA) survivors of childhood cancer using a combination of qualitative and
quantitative methods to examine their diverse life experiences. The ultimate objective of
this research is to provide better services for childhood cancer patients, survivors and
their families. The quantitative analyses provide information on cancer survivors’
perceived physical and mental health, public and self-stigma, social support, spirituality,
optimism, and self-esteem. The qualitative analyses enable study of cancer-related
experiences in the past and the present, the positive and negative impacts of cancer,
family roles, health beliefs, and service needs for cancer survivors. For this dissertation
study, quantitative data was used and the relevant methodology is described in the
following section.
Participants and Procedures
Participants consisted of 227 cancer survivors residing in the community, who
were diagnosed before the age of 19 years, were between 15 and 39 years old at the time
of the study, and had completed cancer treatment. Of those 227 respondents, two
respondents who did not meet the study inclusion criteria and two respondents who did
not complete the survey were excluded from analyses. The final sample for the analyses
contained 223 Korean adolescent and young adult (AYA) survivors of childhood cancer.

24
Participants were recruited in Korea from June 2010 to November 2010. Subjects
were identified through the Korea Childhood Leukemia Foundation’s an existing list of
cancer survivors who had participated in past events and might be interested in
participating in this study. The KCLF directly contacted potential participants, informed
them of this research project and asked them to directly contact the researchers to
participate. Participants were also recruited from Korean advocacy foundations and
support groups for childhood cancer survivors and their parents. Potential participants
were asked to inform any friends who were eligible for the study. This snowball sampling
method was expected to be effective because cancer survivors in Korea are stigmatized
and hard to reach. A 15-minute structured questionnaire and a detailed information sheet
were distributed to potential participants either via mail or email.
The study was approved by the Institutional Review Board (IRB) of the University
of Southern California and written consent was not required. Confidentiality was
discussed with each participant prior to their involvement to ensure that all information
shared remained private. Participation was voluntary. Participants received a book store
gift certificate, valued at approximately $4 (based on the current US currency exchange
rate), for their participation.
Measures
The measures used for this study are described in the following section. Included
are measures of psychological distress, perceived physical functioning, perceived public
stigma towards cancer survivors, self-stigma related to being cancer survivors, self-

25
disclosure about cancer experiences, perceived availability of social support, and
sociodemographic and cancer-related information.
Translation of measures. As recommended by Brislin (1970, 2000), the English
version of the questionnaire was first translated into Korean and then back translated into
English by a bilingual translator with an excellent knowledge of Korean and English. The
translated Korean questionnaire was reviewed by a Korean elementary school language
teacher in order to ensure understanding of questions by the adolescent participants.
Minor discrepancies involving word choice were thoroughly discussed with the PIs and
appropriately revised. In order to increase the reliability of the survey, the Korean version
of the questionnaire was pilot tested with five AYA cancer survivors to confirm
conceptual equivalence between the translated and original measures. Necessary
revisions in wording resulting from the pilot tests were incorporated into the final
questionnaire. Only the Korean version of the questionnaire was used for the study.
Outcome measures: Psychological distress. Psychological distress was assessed
with the Brief Symptom Inventory-18 (BSI-18; Derogatis, 2000), an instrument designed
to screen for depression, somatization, and anxiety in medical and community
populations. Respondents were asked about the degree to which they felt bothered by
each symptom (i.e., somatization, depression, and anxiety) during the previous 7 days.
Responses for each item were scored on a 5-point Likert scale ranging from 0 (never) to 4
(extremely). Missing items were imputed using the average score of the non-missing
items, rounded to the nearest integer (Derogatis, 2000). The raw score of the 18 items
was summed to create the Global Severity Index (GSI) for a total range of 0 to 72, with

26
higher scores indicating higher levels of psychological distress. The GSI scores were then
transformed to T scores (M = 50, SD = 10) based on gender-specific community norms
(Derogatis, 2000), and respondents were classified as having significant levels of
psychological distress if their GSI T scores were equal or greater to a score of 63 (90th
percentile) (Derogatis, 1993).
The BSI-18 has been used with Korean and Korean American cancer survivors
(Lim & Zebrack, 2008) and has been validated for childhood cancer survivors in previous
studies (Recklitis & Rodriguez, 2007; Recklitis et al., 2006; Zabora et al., 2001).
However, there has been concern due to low validity of the factor structure for the BSI
across diverse cultural groups because of cultural variation in patterns of symptom
expression. Specifically, the validity of the BSI for Koreans has been questioned, based
on indication that “a somatization factor is composed of both somatic and cognitive
features among Koreans” (Pang, 2000, p. 207). It may reflect that Koreans consider the
mind as not being separate from the body and combine related symptoms in expressing
distress (Pang, 1989). In addition, Koreans emphasize group harmony and tend to hold
their personal emotions (Kim, Li, & Kim, 1999). Therefore, Koreans may show a higher
level of somatization than other symptoms when assessing their psychological distress
(Pang, 2000). Such cultural variation makes it difficult to compare scores obtained using
the original version and the translated version of the multi-dimensional measure (Van de
Vijver & Leung, 1997). Although a cross-cultural analysis of the BSI-18 concluded the
underlying factors are not robust, the unidimensional global score has shown to be useful
to measure overall psychological distress (Aroian, Patsdaughter, Levin, & Gianan, 1995;

27
Asner-Self, Schreiber, & Marotta, 2006). Therefore, only the global GSI score was used
in this study; the internal consistency reliability for the sample was excellent (α = .88).
Predictors. As the primary predictor variables, the measures of perceived
physical functioning and perceived public stigma are presented in the following section.
Perceived physical functioning. Subjects’ perceived physical functioning was
assessed using the Physical Component Summary (PCS) measures from the Medical
Outcomes Study Short Form-8 (SF-8; Ware, Kosinski, Dewey, & Gandek, 2001). The
SF-8 contains the 8 items assessing both functioning and evaluation of one’s ability to
perform physical activity, with a 4-week recall period. The PCS scores were computed
with higher weights for the following items using a norm-based scoring method (Ware et
al., 2001): physical functioning (e.g. “During the past 4 weeks, how much did physical
health problems limit your usual physical activities?”), role limitations due to physical
health problems (e.g. “During the past 4 weeks, how much difficulty did you have doing
your daily work, both at home and away from home, because of your physical health?”),
bodily pain (e.g. “How much bodily pain have you had during the past 4 weeks?”),
general health (e.g. “Overall, how would you rate your health during the past 4 weeks?”),
and energy/fatigue (e.g. “During the past 4 weeks, how much energy did you have?”).
Each item has a five- or six-point response range, from 1 (not at all) to 5 (extremely) or
from 1 (none) to 6 (very severe). Higher summary PCS scores indicate better perceived
physical functioning.
Perceived public stigma. In order to assess the subjects’ perceived social response
towards a person with a history of cancer, perceived public stigma was measured by

28
using a combination of five items from previous measures. Based on a theoretical
approach using the modified labeling theory (Link et al., 1989; Link et al., 1997), two
items from a social rejection subscale of the Social Impact Scale (SIC; Fife & Wright,
2000) and three items from the Devaluation-Discrimination scale (Link et al., 1989) were
combined to form the measure. Since the items were originally designed for cancer or
HIV/AIDS patients, and persons with mental illness, respectively, further modifications
in wording were made to fit the context for cancer survivors.
Respondents were asked to answer the degree to which the five statements
described how they had been facing difficulties as a cancer survivor: (1) Most people
would be reluctant to date a cancer survivor. (2) Most employers would pass over the
application of a cancer survivor in favor of another applicant. (3) Most people would
willingly accept a cancer survivor as a close friend. (4) Most people would think cancer is
contagious. (5) Most people would act as though cancer survivors are less competent than
others. Responses for each item were scored on a 4-point Likert-type scale ranging from
1 (strongly disagree) to 4 (strongly agree). The index of perceived public stigma was
computed by averaging across items, with higher scores indicating greater levels of
perceived public stigma. In the current sample, the internal consistency reliability (α
= .75) was good.
Cognitive and social mediators. As the cognitive and social mediators, the
measures of self-stigma, self-disclosure, and social support availability are presented in
the following section.

29
Self-stigma. Self-stigma related to being a cancer survivor was measured with a
subscale (internalized shame) of the Social Impact Scale (SIC; Fife & Wright, 2000) from
a theoretical basis using the modified labeling theory (Link et al., 1989; Link et al., 1997).
From an original subscale, two items assessing internalized shame in relation to
disclosure of cancer history (e.g., “I do not feel I can be open with others about my
cancer history” and “I feel I need to keep my cancer history a secret”), and one item
assessing self-blame for cancer (e.g., “I feel I am at least partially to blame for my
cancer”) were selected. Similar to the measures of perceived public stigma, modifications
in wording were made to fit the context for cancer survivors. Responses for each item
were scored on a 4-point Likert-type scale ranging from 1 (strongly disagree) to 4
(strongly agree). The index of self-stigma was computed by averaging across items, with
higher scores indicating greater levels of self-stigma. In the current sample, the internal
consistency reliability (α = .68) was acceptable.
Self-disclosure. Self-disclosure about cancer experiences was measured with the
following single item, “Have you talked with other people about your cancer
experiences?”. The original item was used in prior research to assess levels of self-
disclosure about stressful events (Lepore, Silver, Wortman, & Wayment, 1996; Murray,
Lamnin, & Carver, 1989) and was used with a cancer survivor sample (Cordova,
Cunningham, Carlson, & Andrykowskiet, 2001). Slight adjustments were required to
make the wording of the question relevant to cancer survivors. Response was scored on a
7-point Likert scale ranging from 1 (never) to 7 (almost always). Higher scores reflect
greater levels of self-disclosure about cancer experiences.

30
Perceived availability of social support. Subjects’ perceived availability of social
support was measured by using the Medical Outcomes Study Social Support Survey
(MOS-SSS; Sherbourne & Stewart, 1991). The MOS-SSS consists of 19 items assessing
the perceived availability of social support with four subscales (emotional-informational
support, tangible support, affectionate support, and positive social interaction), and an
overall social support index. The respondents were asked to indicate how often they think
each of the four types of support is available to them if they need it.
Emotional/informational support (8 items) measures the expression of positive affect and
empathetic understanding or the offering of advice, information, or guidance. Example
items include “Someone to share your most private worries and fears with” and
“Someone to give you good advice about a crisis”. Tangible support (4 items) measures
the provision of material aid or behavioral assistance. Some examples of items are
“Someone to prepare your meals if you were unable to do it yourself” and “Someone to
help you if you were confined to bed”. Affectionate support (3 items) measures
expressions of love and affection. Example items are “Someone to love and make you
feel wanted” and “Someone who hugs you”. Positive social interaction (3 items)
measures the availability of other persons to do fun things with respondents. Examples of
items include “Someone to do something enjoyable with” and “Someone to have a good
time with”. General support (1 item) was measured by asking if the respondents have
someone to do things with them to help them get their minds off of things. Responses for
each item were scored on a 5-point Likert-type scale with 1 = none of the time, 2 = a little
of the time, 3 = some of the time, 4 = most of the time, and 5 = all of the time. The index

31
of each subscale was computed by averaging across items. Higher scores reflected greater
levels of perceived social support availability.
The reliability and validity of the measure has been established with a US
population (Sherbourne & Stewart, 1991) as well as a Korean population (Wong, Yoo, &
Stewart, 2007). Previous research demonstrated that the MOS-SSS using four subscales
is a better fit than the unidimensional factor model (Sherbourne & Stewart, 1991),
therefore, the four subscales, excluding the general support index, were used. In this
study, the internal consistency reliability of the four subscales of the MOS-SSS was
excellent (alpha coefficient for the emotional-informational support = .956, tangible
support = .906, affectionate support = .941, positive social interaction = .940).
Sociodemographic variables. Sociodemographic variables included age, gender,
marital status, education, employment, residential area, economic status, and religion.
Age was measured in years and the response was categorized into three groups:
adolescent (15 to 18 years), emerging adult (19 to 25 years), and young adult (26 to 39
years). Although in the US emerging adults are generally referred to as those between 18
and 25 years of age, between-country variations are found because of differences in
educational systems and related policies (Arnett, 2004). Since Koreans usually enter
college at around 19 years old, emerging adult was defined as 19 to 25 years of age.
Marital status was assessed as 1 = never married, 2 = married, 3 = living with a partner,
4 = divorced, 5 = separated, and 6 = widowed. Education was measured as 1 = less than
high school, 2 = high school graduate, and 3 = college graduate. Employment was
measured as seven categories (e.g., full-time, part-time, self-employed, unemployment,

32
student, housewife, and volunteer) and was collapsed into three categories: employed
(e.g., full-time, part-time, and self-employed), unemployed, and not in the workforce (e.g.
student, housewife, and volunteer). Residential area was measured as three categories:
metropolitan area, mid-sized city, and rural area or small city. Economic status was
measured as four categories (e.g., inadequate funds for basic goods, adequate funds for
basic goods, but inadequate for comfortable living, stable but not wealthy, and wealthy)
and religion was measured as five categories (no religion, Protestant, Buddhist, Catholic,
and other).
Cancer-related variables. Cancer-related variables included type of cancer,
recurrence, age at diagnosis, and time since diagnosis. Respondents were asked to choose
a type of cancer at diagnosis using five categories that are reported in current literature as
frequent childhood cancer types: brain tumors, Lymphoma, Central Nervous System
(CNS) tumors, Leukemia, and kidney cancers. The respondents were also asked to
specify any other cancer type that was diagnosed other than those five types. The cancer
type was, then, collapsed into three categories; Hematological cancers, CNS or brain
tumors, and solid or soft tissue tumors. Cancer recurrence was measured as recurred and
never recurred. Age at diagnosis was measured in years and then divided into three
categories: early childhood (less than 5 years), school age (6 to 12 years), and adolescent
(13 to 18 years). Time since diagnosis was likewise measured in years and then recoded
into 4 categories: less than 10 years, 10 to 14 years, 15 to 19 years, and 20 years or more.

33
Data Analyses
Prior to the main analyses, descriptive statistics for sociodemographic variables
(age, gender, marital status, education, employment, residential area, economic status,
and religion) and cancer-related variables (diagnosed cancer type, recurrence, age at
diagnosis, and time since diagnosis) were reported to describe the participants’
characteristics. The primary analyses were then conducted to address the following
research questions and hypotheses for the four research aims.
Research Aim 1. The first research aim was to examine the overall prevalence of
psychological distress and to compare the profile of cancer survivors in relation to
psychological distress. Specifically, this study aimed to examine sociodemographic and
cancer-related characteristics, perceived physical functioning, perceived public stigma,
and cognitive and social variables (i.e., self-stigma, self-disclosure, and perceived social
support availability) between AYA childhood cancer survivors with and without
significant levels of psychological distress.

Research question 1a: How prevalent is psychological distress among AYA
childhood cancer survivors?

For the first research question, descriptive statistics were conducted to summarize
the survivors’ level of psychological distress using the average GSI T scores. One-sample
t-tests were performed to compare the survivors’ average GSI T score with a T score of
50 which is normed for community populations. Binomial proportion tests were

34
conducted to compare the proportion of survivors reporting significant levels of
psychological distress (GSI T score > 63) with the expected proportion of 10% on the
basis of US community norms. All analyses were conducted using SPSS 16.0 (SPSS, Inc.,
Chicago IL).

Research question 1b: To what extent do AYA childhood cancer survivors with
and without significant levels of psychological distress
differ in sociodemographics, cancer-related characteristics,
perceived physical functioning, perceived public stigma,
and cognitive and social variables (self-stigma, self-
disclosure, and perceived availability of social support)?

For the second research question, the dichotomy of ‘distressed group’ and ‘non-
distressed group’ for the BSI-18 was used to determine the prevalence rate of
psychological distress. Each variable was then compared in the two groups of survivors
with and without significant levels of psychological distress. First, the degree to which
the two groups were comparable on sociodemographic and cancer-related variables was
examined by a set of Pearson's chi-square test. Marital status was not included in the chi-
square test due to the low variability of the variable (i.e., over 97% of respondents had
never married). For the analyses the following categorical variables with small observed
cell frequencies were considered by collapsing categories. Educational level was
dichotomized to indicate less than a college degree or completion of a college degree.

35
Economic status was likewise dichotomized into stable (not wealthy but stable or
wealthy) and unstable (inadequate funds for basic goods or comfortable living). Similarly,
residential area was dichotomized into metropolitan area and mid-size or small city;
religion was dichotomized into having religion and no religion. For these dichotomous
variables, a chi-square test with the Yates' correction (Yates, 1984) was used to increase
the accuracy of the resulting probability. Second, independent samples t-tests were used
to compare the mean difference between two groups with and without significant levels
of psychological distress in perceived physical functioning, perceived public stigma, self-
stigma, self-disclosure, and perceived availability of social support. All the variables in
these analyses were treated as a continuous variable. All analyses were conducted using
SPSS 16.0 (SPSS, Inc., Chicago IL).
Research Aim 2. The second research aim was to identify significant correlates
of psychological distress in AYA survivors of childhood cancer. Specific attention was
given to the perceived physical functioning and perceived public stigma as potential risk
factors for psychological distress, taking into account possible sociodemographic and
cancer-related correlates.

Hypothesis 2a: Sociodemographic characteristics will be associated with
significant levels of psychological distress.

Hypothesis 2b: Cancer-related characteristics will be associated with significant
levels of psychological distress.

36
For the two hypotheses, a set of univariate logistic regression (ULR) analyses
were used with presence or absence of significant levels of psychological distress (i.e.,
distressed group vs. non-distressed group) as a criterion. Using dichotomized variable
provides ease of interpretation of findings using odds ratios (OR) and does not
necessarily decrease the measured strength of association between variables (Farrington
& Loeber, 2000). Thus, ULR analyses were performed separately to examine the effects
of each sociodemographic and cancer-related characteristic on the presence and absence
of significant levels of psychological distress without the assumptions of normality for
the variables. All the sociodemographic variables (age, gender, marital status, education,
employment, residential area, economic status, and religion) and cancer-related variables
(cancer type, recurrence, age at diagnosis, and time since diagnosis) were included as
categorical variables in the analyses. Cancer type was recoded with CNS or brain tumors
serving as the reference group as it was expected to differ from the other two types of
cancer (Zeltzer et al., 2009). Odds of having significant levels of psychological distress
and confidence intervals (CI) generated from the analyses were used for interpretation.
All analyses were conducted using SPSS 16.0 (SPSS, Inc., Chicago IL).

Hypothesis 2c: Perceived physical functioning and perceived public stigma will
be associated with significant levels of psychological distress,
controlling for sociodemographic and cancer-related correlates.

37
For this hypothesis, multivariate logistic regression (MLR) analysis was
performed with the presence or absence of significant levels of psychological distress as
the criterion and perceived physical functioning and perceived public stigma as predictors,
taking into account sociodemographic and cancer-related correlates. Because ULR results
might be biased when the influence of other important sociodemographic and cancer-
related predictors are not controlled for, MLR was selected to examine the unique effect
of perceived physical functioning and perceived public stigma on significant levels of
psychological distress. Therefore, significant sociodemographic and cancer-related
variables at the 5% level in the ULR were retained as covariates in a MLR model
predicting significant levels of psychological distress. For the analyses, perceived
physical functioning and perceived public stigma were treated as continuous variables
and all other covariates were treated as categorical variables. All analyses were conducted
using SPSS 16.0 (SPSS, Inc., Chicago IL).
Research Aim 3. The third research aim was to test a model of the effects of
perceived physical functioning and perceived public stigma on psychological distress as
mediated through three cognitive and social factors (self-stigma, self-disclosure, and
perceived availability of social support) in AYA childhood cancer survivors.

Hypothesis 3a: Perceived better physical functioning will predict lower levels of
psychological distress, and this relationship will be mediated by
the level of perceived social support availability.

38
Hypothesis 3b: Higher levels of perceived public stigma will predict greater levels
of psychological distress, and this relationship will be mediated by
level of self-disclosure, self-stigma and social support availability.

For the third research aim, structural equation modeling (SEM) was used in order
to explore inter-related dependencies between perceived physical functioning, perceived
public stigma, self-stigma, self-disclosure, perceived availability of social support, and
psychological distress. SEM was selected to estimate simultaneously hypothesized causal
relationships among variables to determine whether an obtained sample of data supported
these relationships (Bollen, 1989). The selection of variables for the SEM and their
positions in the model was based on theory outlined in Chapter 2. As suggested by
Anderson and Gerbing (1988), the dissertation followed two-step approaches to SEM. In
the first step, the measurement models for two latent variables (i.e., perceived public
stigma and perceived availability of social support) were tested by using a confirmatory
factor analysis (CFA). Once the measurement model was estimated and a proper solution
was derived, a structural model based on the proposed conceptual model was assessed to
test the hypothesized relationships, using goodness of fit criteria.
The proposed structural model hypothesized simultaneous mediation by multiple
variables, referred to as a multiple mediation model (Preacher & Hayes, 2008, p. 880).
The multiple mediation effects within the same model rather than separate simple
mediation models were tested to investigate the specific indirect effects of each mediator,
controlling for the effects of the other mediators (Preacher & Hayes, 2008). Preacher and

39
Hayes (2008) have recommended that testing a multiple mediation model involve (a) an
analysis of the total indirect effect and (b) an analysis of the specific indirect effect. The
total indirect effect was defined as the sum of the indirect effects across all mediators in a
given model, whereas the specific indirect effect was defined as the indirect effect of a
particular mediator (Preacher & Hayes, 2008). Thus, two mediated effects were
examined: (1) the effect of perceived physical functioning on psychological distress as
mediated by social support availability, and (2) the effect of perceived public stigma on
psychological distress as mediated by self-stigma, self-disclosure, and social support
availability. For each relationship, total and specific indirect effects were examined.
For this analysis, psychological distress was included as a continuously
distributed observed variable, using gender specific GSI T scores. Psychological distress
was used in its continuous (rather than dichotomous) form as it ensured that maximum
variability in the data and provided rich information to examine effects of cognitive and
social factors on the survivors with different levels of psychological distress. All the
analyses were conducted with the maximum-likelihood (ML) estimation in Mplus 6.12
(Muthén & Muthén, 2010). The following section details the procedures pertaining to
parcel construction, testing the overall model fit, and bootstrapping.
Parcel construction. Prior to establishing a measurement model and assessing a
complex structural model, observed indicators (parcels) for the two latent variables (i.e.,
perceived public stigma and social support availability) were created, following the
recommendation of Russell, Kahn, Spoth, and Altmaier (1998). A parcel can be defined
as, "the aggregate-level indicator comprised of the sum or average of two or more

40
items ..." (Little, Cunningham, Shahar, & Widaman, 2002, p. 152). Parceling was
employed to provide “more reliable and valid indicators of the underlying factors and to
provide more efficient parameter estimates” (Bagozzi & Heatherton, 1994; Bandalos,
2002; Little et al., 2002; Russell et al., 1998).
Social support availability. For the social support availability latent variable, the
partial aggregation approach was used to provide greater reliability (Loehlin, 1992) by
aggregating indicators of each dimension of the overall construct (Bagozzi &
Heatherington, 1994). Thus, four parcels were created representing each type of social
support availability (i.e., emotional-informational support, tangible support, affectionate
support, and positive social interaction) by summing all items in each subscale and
forming a single summated composite. Correlation between error terms for each
composite was allowed for two reasons. First, this variable had the same measurement
scale and the respondents had answered the questions relating to each type of support in
the same way. Therefore, the use of correlated errors was justified (Dunne, Everitt, &
Pickles, 1993; Kline 2003).
Perceived public stigma. For the measure of perceived public stigma, three
unidimensional parcels were created. Because response categories for this variable are all
ordinal with 4-point Likert-type scale, creating parcels was advantageous for meeting the
assumptions of the ML method associated with SEM analyses. First, the item-to-
construct relations were examined to build balanced parcels by using the loadings from
the exploratory factor analyses with the maximum likelihood method. Then, pairs of the

41
highest and lowest items were assigned to a parcel to equalize the average loadings of
each parcel on its respective factor (Little et al., 2002).
Self-stigma. Preliminary CFA of the measurement model for self-stigma indicated
that all individual loadings for the three items were statistically significant (p < .001).
However, one indicator showed a lower factor loading (unstandardized factor loading
= .032; standardized factor loading = 0.29) relative to the other two items (unstandardized
factor loading = 1.0 and 1.0; unstandardized factor loading = 0.81 and 0.93, respectively),
indicating this item actually taps a different value dimension of self-stigma from the other
two items. This item assesses self-blame for cancer, whereas the other two items assess
internalized shame in relation to disclosure of cancer on the theoretical base. Thus,
separating the indicator with low factor loading from the other two indicators was
justified and, thereby, self-stigma was split into two separate observed variables
representing internalized shame with the sum of two items and self-blame as one item.
Goodness of fit criteria. The overall goodness of fit of the model with the data
was examined using four fit indexes: The Comparative Fit Index (CFI) (Bentler, 1990),
Tucker-Lewis Index (TLI) (Tucker & Lewis, 1973), root mean square error of
approximation (RMSEA) (Steiger, 1990), and the standardized root-mean-square residual
(SRMR). CFI and TLI values of at least .90 indicate an adequate fit, and values of .95 or
greater indicate a strong fit. For RMSEA, values of below .08 are generally considered to
be reasonable (Browne & Cudeck, 1993; Kline, 2005; MacCallum, Browne, & Sugawara,
1996) and .06 or below signify a good model (Hu & Bentler, 1999). Similarly, for the
SRMR, values of .08 or less indicate that the model adequately fits the data (Hu &

42
Bentler, 1999). The chi-square statistic for model fit was not evaluated as the test is
highly sensitive to sample size especially if the observations are greater than 200 (Bollen,
1989; Chen, 2007; Cheung & Rensvold, 2002). In this study, the chi-square statistic may
not be a very useful fit index due to the skewness of variables and the large number of
parameters. An alternate evaluation of the χ
2
statistic was examined by using the ratio of
χ
2
to the degrees of freedom (df) for the model (Joreskog & Sorbom, 1993). As Kline
(2005) suggested, a χ
2
/df ratio of 3 or less is a reasonably good indicator of model fit.
Bootstrapping. A bootstrap procedure was conducted to determine the
significance of statistical estimates for indirect effects in predicting psychological distress
(Efron & Tibshirani, 1993). MacKinnon, Lockwood, Hoffman, West, and Sheets (2002)
showed that the bias-corrected (BC) bootstrap method provides the best balance between
Type I and Type II error rates of all available approaches for detection of indirect effects.
A bootstrap analysis provides greater statistical power without assuming multivariate
normality in the sampling distribution (Mallinckrodt, Abraham, Wei, & Russell, 2006;
Preacher & Hayes, 2008).
As suggested by Shrout and Bolger (2002), 1,000 bootstrap samples from the
original data set (N = 223) were created through random sampling with replacement. As
recommended by Preacher and Hayes (2008), to test for multiple mediation, a parameter
estimate of the total as well as the specific indirect effects of two predictors (perceived
physical functioning and perceived public stigma) on psychological distress through the
three mediators and their respective 95% BC bootstrap confidence intervals (CI) were
generated by using 1,000 bootstrap samples. If the 95% BC bootstrap CI for the

43
parameter estimate does not include zero, the indirect effect is considered statistically
significant at the .05 level (MacKnnon, 2008; Mallinckrodt et al., 2006; Preacher &
Hayes, 2008; Shrout & Bolger, 2002).
Research Aim 4. The fourth research aim was to examine gender differences
within the mediated effects of perceived physical functioning and perceived public stigma
on psychological distress through self-stigma, self-disclosure and social support
availability among AYA childhood cancer survivors.

Hypothesis 4a: The mediated effects of physical functioning on psychological
distress through social support availability will be different for
male and female survivors.

Hypothesis 4b: The mediated effects of perceived public stigma on psychological
distress through self-stigma, self-disclosure and social support
availability will be different for male and female survivors.

For these research hypotheses, the gender differences in mean scores of major
study variables were examined using independent sample t-tests. Then, the multiple
mediation models were tested separately for subgroups of males and females to examine
mediated effects of perceived physical functioning and perceived public stigma on
psychological distress, using SEM and bootstrap analyses. All the analyses were
conducted with the ML estimation in Mplus 6.12 (Muthén & Muthén, 2010).

44
CHAPTER 5: RESULTS
Sample Characteristics
Sociodemographic characteristics. The sociodemographic characteristics for the
sample of 223 childhood cancer survivors are presented in Table 1. The proportion of the
male and female participants was similar, and the mean age was 21.9 years (SD = 4.69),
ranging from 15 to 38 years. Most of the participants had never been married (97.3%, n =
216), had less than a college degree (67.6%, n = 150), and were not in the workforce
(74.2%, n = 164) as they were either students or housewives. Although over half of the
respondents lived in a metropolitan area (58.1%, n = 129), there was adequate
representations of persons from mid-sized cities and rural areas. Over two-thirds of the
respondents (71.4%, n = 155) had a stable or wealthy economic status. A majority of the
respondents (63.2%, n = 139) reported a religious affiliation, such as Christian or
Buddhist.
Cancer-related characteristics. A detailed description of cancer-related
characteristics among the survivors is provided in Table 2. The most prominent type of
cancer was hematological cancer, followed by solid or soft tissue tumors and central
nervous system (CNS) or brain tumors. Only a small percentage of survivors (14.2%)
reported experiencing cancer recurrence. The average age at diagnosis was 9.9 years (SD
= 4.39), ranging from birth to 18 years and the average time since diagnosis was 12.0
years (SD = 5.91), ranging from 2 to 29 years.

45
Table 1
Sociodemographic Characteristics of the Participants (n = 223)
Characteristic n %
Age
Adolescent (15 – 18) 56 25.2
Emerging adult (19 – 25) 124 55.9
Young adult (26 – 39) 42 18.9
Gender
Male 130 58.6
Female 92 41.4
Marital status
Never married 216 97.3
Married 6 2.7
Education
< High school 63 28.4
High school graduate 87 39.2
College graduate 72 32.4
Employment
Employed 39 17.6
Unemployed 18 8.1
Not in workforce 164 74.2

46
Table 1 (continued)
Characteristic n %
Residential area
Metropolitan area 129 58.1
Mid-size city 76 34.2
Rural/small city 17 7.7
Economic status
Inadequate funds for basic goods 10 4.6
Adequate funds for basic goods 52 24.0
Stable, but not wealthy 140 64.5
Wealthy 15 6.9
Religion
No religion 81 36.8
Protestant 63 28.6
Buddhist 49 22.3
Catholic 26 11.8
Other 1 0.6
Note.

N sizes fluctuate slightly due to missing values.

47
Table 2
Cancer-Related Characteristics of the Participants (n = 223)
Characteristic n %
Diagnosed cancer type
Hematological cancers 157 71.7
Solid or soft tissue tumors 32 14.6
CNS or brain tumors 30 13.7
Cancer recurrence
Yes 31 14.2
No 187 85.8
Age at diagnosis
Early childhood ( ≤ 5)
51 24.2
School age (6 – 12) 89 42.2
Adolescence (13 – 18) 71 33.6
Time since diagnosis
< 10 years 84 39.8
10 – 14 years 62 29.4
15 – 19 years 39 18.5
≥ 20 years 26 12.3
CNS = Central Nervous System.
Note. N sizes fluctuate slightly due to missing values.

48
Results for Research Aim 1
Aim 1 examines the overall prevalence of psychological distress among this
sample of childhood cancer survivors in Korea. Further comparisons are made between
survivors with and without significant levels of psychological distress in light of
sociodemographics, cancer-related characteristics, perceived physical functioning,
perceived public stigma, and cognitive and social factors (self-stigma, self-disclosure, and
perceived availability of social support).
Prevalence of psychological distress. To describe the survivors’ level of
psychological distress on the Brief Symptom Inventory-18 (BSI-18), the survivors’
average Global Severity Index (GSI) T score was compared with community norms as
presented in Table 3. Participants’ mean GSI T scores (M = 54.9, SD = 9.15) were
significantly higher than the normative mean of 50. Both male (M = 53.8) and female
survivors (M = 56.5) reported higher levels of psychological distress (p < .001).
The BSI-18 scores revealed an overall prevalence rate of psychological distress of
20.6% (n = 46) as also presented in Table 3. A significantly higher proportion of
survivors—18.5% of men and 23.9% of women were classified as having significant
levels of psychological distress, compared with the expected proportion of 10%
(p < .001).

49
Table 3
Comparison of the Prevalence of Psychological Distress between Survivors and the Norm
Population (n = 222)
GSI score
N M SD t-test
a

Male 130 53.8 9.63 4.536
***

Female 92 56.5 8.23 7.508
***

Total 222 54.9 9.15 8.003
***

Distressed
b

N n % Z test
c

Male 130 24 18.5 1.02
***

Female 92 22 23.9 4.44
***

Total 222 46 20.6 5.21
***

BSI = Brief Symptom Inventory; GSI = Global Severity Index; SD = Standard Deviations.
Note. One case with missing gender was not included. Comparisons were made using the
US norms.
a
Mean differences with the T score of 50 were tested.
b
This group represents
the survivors that exceeded a T score of 63 for the Global Severity Index.
c
The difference
of proportion of distressed survivors to expected 10% was tested.
***
p < .001.

50
Sociodemographic characteristics of survivors by prevalence of psychological
distress. Table 4 presents data on sociodemographic characteristics of survivors with and
without significant levels of psychological distress. The results of chi-square analyses
indicated that of the sociodemographic variables measured, psychological distress was
related significantly to age (χ
2
= 10.613, df = 2, p < .01) and economic status (χ
2
= 5.463,
df = 1, p < .05).
For both distressed and non-distressed survivors, over half of the survivors were
emerging adults (distressed survivors, 60.9%; non-distressed survivors, 54.5%). While
30.4% (n = 14) were young adults and only 8.7% (n = 4) were adolescents among
distressed survivors, 29.5% (n = 52) were adolescents and 15.9% (n = 28) were young
adults among non-distressed survivors. For those with significant levels of psychological
distress, the percentages of survivors with a stable economic status (56.5%, n = 26) and
an unstable economic status (43.5%, n = 20) were similar, whereas over three quarters
(75.4%, n = 129) had a stable economic status and 24.6% (n = 42) had an unstable
economic status among non-distressed survivors. Characteristics of the survivors with
and without significant levels of psychological distress did not statistically differ by
gender, marital status, education, employment, residential area, or religion.

51
Table 4
Sociodemographic Characteristics of Survivors by Prevalence of Psychological Distress
(n = 223)

Distressed
a
(n = 46)
Non-distressed
(n = 177)

Characteristic n % n % χ
2

Age 10.613
**

Adolescent (15 – 18) 4 8.7 52 29.5
Emerging adult (19 – 25) 28 60.9 96 54.5
Young adult (26 – 39) 14 30.4 28 15.9
Gender
b
.671
Male 24 52.2 106 60.2
Female 22 47.8 70 39.8
Marital status
c
NS
Never married 44 95.7 172 97.7
Married 2 4.3 4 2.3
Education
b
1.940
< College graduate 26 57.8 124 70.1
College graduate 19 42.2 53 29.9
Employment 3.264
Employed 10 22.2 29 16.5
Unemployed 6 13.3 12 6.8
Not in workforce 29 64.4 135 76.7

52
Table 4 (continued)
Distressed
a
Non-distressed
Characteristic n % n % χ
2

Residential area
b
.000
Metropolitan area 27 58.7 102 58.0
Mid-size or small city 19 41.3 74 42.0
Economic status
b
5.463
*

Stable 26 56.5 129 75.4
Unstable 20 43.5 42 24.6
Religion
b
.244
No religion 15 32.6 66 37.9
Having religion 31 67.4 108 62.1
Note. Observed frequencies and percentages within dichotomized groups for
psychological distress were reported.
a
This group represents the survivors that exceeded
a T score of 63 for the Global Severity Index.
b
Yates correction was used for the 2x2
table.
c
Chi-square statistics for marital status were not calculated because of the low
variability.

*
p < .05.
**
p < .01.

53
Cancer-related characteristics of survivors by prevalence of psychological
distress. Table 5 details the cancer-related characteristics of survivors with and without
significant levels of psychological distress. While there was no difference in terms of
diagnosed cancer type, cancer recurrence and age at diagnosis between the survivors with
and without psychological distress, differences did exist in terms of time since diagnosis
(χ
2
= 20.599, df = 2, p < .001). The results indicated that those who were diagnosed fewer
than 10 years earlier represented the highest proportion among both distressed (35.6%, n
=16) and non-distressed survivors (41.0%, n = 68). The survivors who were diagnosed
over 20 years (28.9%, n = 13) and between 15 to 19 years ago (24.4%, n =11) represented
a relatively higher proportion, followed by 10 to 14 years (11.1%, n = 5) among
distressed survivors, while the lesser time since diagnosis represented more non-
distressed survivors (10 to 14 years, 34.3%; 15 to 19 years, 16.9%; over 20 years, 7.8%).
Although the association with diagnosed cancer type was not statistically
significant (χ
2
= 5.781, df = 2, p = .056), a notable difference was observed between
distressed and non-distressed survivors. Over 70% of the survivors were diagnosed with
hematological cancers among both distressed (73.9%, n = 34) and non-distressed
survivors (71.1%, n = 123). The proportion of survivors that were diagnosed with solid or
soft tissue tumors (21.7%, n = 10) was relatively higher than those with CNS or brain
tumors (4.3%, n = 2) among distressed survivors in comparison to non-distressed
survivors that represented similar percentages (solid or soft tissue tumors, 16.2%; CNS or
brain tumors, 12.7%).

54
Table 5
Cancer-Related Characteristics of Survivors by Prevalence of Psychological Distress
(n = 223)

Distressed
a
(n = 46)

Non-distressed
(n = 177)

Characteristic n % n % χ
2

Diagnosed cancer type 5.781
Hematological cancers 34 73.9 123 71.1
Solid or soft tissue tumors 10 21.7 22 16.2
CNS or brain tumors 2 4.3 28 12.7
Cancer recurrence
b
1.013
Yes 9 20 22 12.7
No 36 80 151 87.3
Age at diagnosis 1.878
Early childhood (≤ 5) 13 28.9 38 22.9
School age (6 – 12) 15 33.3 74 44.6
Adolescence (13 – 17) 17 37.8 54 32.5
Time since diagnosis 20.599
***

< 10 years 16 35.6 68 41.0
10 – 14 years 5 11.1 57 34.3
15 – 19 years 11 24.4 28 16.9
≥ 20 years 13 28.9 13 7.8
CNS = Central Nervous System.
Note. Observed frequencies and percentages within dichotomized groups for
psychological distress were reported.
a
This group represents the survivors that exceeded
a T score of 63 for the Global Severity Index.
b
Yates correction was used for the 2x2
table.

***
p < .001.

55
Differences in the study variables by prevalence of psychological distress.
Table 6 contains the mean score and standard deviations for the six major study variables
(i.e., perceived physical functioning, perceived public stigma, internalized shame, self-
blame, self-disclosure, and perceived availability of social support) among survivors with
and without significant levels of psychological distress. The findings produced using
independent sample t-tests demonstrated that perceived physical functioning (t = 4.387,
df = 219, p < .001), perceived public stigma (t = –3.949, df = 219, p < .001), internalized
shame (t = –2.751, df = 218, p < .01), and perceived availability in three domains of
social support (emotional-informational support, t = 4.094, df = 219, p < .001;
affectionate support, t = 2.152, df = 220, p < .05; positive social interaction, t = 5.280, df
= 218, p < .001) differed by prevalence of psychological distress. Self-blame representing
self-stigma and self-disclosure was not associated with prevalence of psychological
distress.
Survivors with significant levels of psychological distress vs. those without
psychological distress reported significantly lower mean scores of perceived physical
functioning (M = 52.77 versus M = 53.72), while they showed significantly higher mean
scores of perceived public stigma (M = 2.28 versus M = 1.87) and internalized shame (M
= 4.49 versus M = 3.67). Distressed survivors reported significantly lower levels of
perceived availability in emotional-informational support (M = 3.25 versus M = 3.89),
affectionate support (M = 3.90 versus M = 4.27), and positive social interaction (M =
3.37 versus M = 4.21), but not in tangible support than non-distressed survivors.

56
Table 6
Differences in the Study Variables by Prevalence of Psychological Distress (n = 223)
Total
Mean
Distressed
a

(n = 46)
Non-distressed
(n = 177)

Variable Mean SD Mean SD t value df
Physical functioning 52.77 49.05 6.96 53.72 6.21 4.387
***
219
Public stigma 1.95 2.28 .62 1.87 .61 –3.949
***
219
Self-stigma: Shame 3.84 4.49 1.91 3.67 1.75 –2.751
**
218
Self-stigma: Self-blame 1.89 1.91 .94 1.88 .93 –.209 220
Self-disclosure 3.82 3.80 1.58 3.83 1.53 .128 217
Social support availability
Emotional-informational
support
3.75 3.25 1.04

3.89 .91 4.094
***
219
Tangible support
b
4.05 3.85 1.18 4.10 .92 1.334 60
Affectionate support 4.19 3.90 1.09 4.27 1.01 2.152
*
220
Positive social
interaction
4.03 3.37 1.01

4.21 .95 5.280
***
218

Note.

All means are item-level means, not sums of the items, except for perceived
physical functioning.
a
This group represents the number of survivors and percentages
that exceeded a T score of 63 for the Global Severity Index.
b
Equal variance not assumed.
*
p < .05.
***
p < .001.

57
Results for Research Aim 2
Aim 2 identified sociodemographic and cancer-related correlates of psychological
distress and, then, examined perceived physical functioning and perceived public stigma
as potential risk factors for psychological distress, taking into account possible
sociodemographic and cancer-related correlates.
Sociodemographic correlates of psychological distress. Table 7 shows the
prevalence of psychological distress by sociodemographic characteristics and possible
exploratory factors by univariate logistic regression (ULR). In support of hypothesis 2a,
results indicated significant associations of prevalence of psychological distress with the
age and economic status. Emerging adults between 19 and 25 years old (OR = 3.79, 95%
CI = 1.26 to 11.40, p < .05), young adults between 26 and 39 years old (OR = 6.50, 95%
CI = 1.95 to 21.63, p < .01) and those with unstable economic status (OR = 2.36, 95% CI
= 1.20 to 4.66, p < .05) were more likely to be psychologically distressed than
adolescents between 15 and 18 years old and those with stable economic status. There
was no association between psychological distress and gender, marital status, education,
employment, residential area, or religion.
Cancer-related characteristic correlates of psychological distress. Table 8
shows the prevalence of psychological distress by cancer-related characteristics and
possible exploratory factors using ULR. The results indicated significant associations of
prevalence of psychological distress by cancer type and time since diagnosis, supporting
hypothesis 2b. The survivors diagnosed with solid or soft tissue tumors (OR = 6.36, 95%
CI = 1.26 to 32.08, p < .05) were more likely to be psychologically distressed than those

58
diagnosed with CNS or brain tumors. Those diagnosed over 20 years earlier (OR = 4.25,
95% CI = 1.66 to 10.90, p < .01) were at a higher risk of being distressed than those
diagnosed less than 10 years earlier. Age at diagnosis and recurrence were not related to
presence of psychological distress.
Multivariate correlates of psychological distress. Table 9 shows the results of
multivariate analyses used to determine the salient predictors of psychological distress.
Based on the results of ULR analyses, the multivariate model included only the
covariates that were significant at the bivariate level (i.e., age, economic status, cancer
type, and time since diagnosis). Results indicated that survivors who perceived better
health functioning (OR = .92, 95% CI = .86 to .98, p < .01) were less likely to be
distressed. Conversely, survivors who perceived higher levels of public stigma (OR =
1.25, 95% CI = 1.09 to 1.45, p < .01) were more likely to be at risk for having significant
levels of psychological distress, supporting hypothesis 2c. Although all the covariates
were found to be significantly associated with psychological distress at bivariate level, it
remained significant only in the case of age (emerging adults, OR = 4.04, 95% CI = 1.12
to 14.50, p < .05) and cancer type (hematological cancers, OR = .10.60, 95% CI = 1.08 to
104.45, p < .05; solid or soft tissue tumors, OR = 27.50, 95% CI = 2.39 to 316.19, p
< .01) when it was introduced in multivariate analyses.

59
Table 7
Sociodemographic Correlates of Psychological Distress (n = 223)

Distressed
a
(n = 46)
Univariate Regression
Characteristic n %
b
OR
c
95% CI
Age
Adolescent (15 – 18) 4 7.1 1.00 Reference
Emerging adult (19 – 25) 28 22.6 3.79
*
1.26 to 11.40
Young adult (26 – 39) 14 33.3 6.50
**
1.95 to 21.63
Gender
Male 24 18.5 1.00 Reference
Female 22 23.9 1.39 .72 to 2.67
Marital status
Never married 44 20.4 1.00 Reference
Married 2 33.3 1.96 .35 to 11.02
Education
< College graduate 26 17.3 1.00 Reference
College graduate 19 26.4 1.71 .87 to 3.35
Employment
Employed 10 25.6 1.00 Reference
Unemployed 6 33.3 1.45 .43 to 4.89
Not in workforce 29 17.7 .62 .27 to 1.42

60
Table 7 (continued)

Distressed
a
(n = 46)
Univariate Regression
Characteristic n % OR
b
95% CI
Employment
Employed 10 25.6 1.00 Reference
Unemployed 6 33.3 1.45 .43 to 4.89
Not in workforce 29 17.7 .62 .27 to 1.42
Residential area
Metropolitan area 27 20.9 1.00 Reference
Mid-size/ small city 19 20.4 .97 .50 to 1.87
Economic status
Stable 26 16.8 1.00 Reference
Unstable 20 32.3 2.36
*
1.20 to 4.66
Religion
No religion 15 18.5 1.00 Reference
Having religion 31 22.3 1.26 .64 to 2.51
CI = Confidence Interval; OR = Odds Ratio.
Note. Observed frequencies and percentages within each sociodemographic
characteristics were reported.
a
This group represents the survivors that exceeded a T
score of 63 for the Global Severity Index.
b
OR = Odds ratio for being classified as
having a significant level of psychological distress.
*
p < .05.
**
p < .01.

61
Table 8
Cancer-Related Correlates of Psychological Distress (n = 223)
Distressed
a

Univariate Regression
Characteristic n %

OR
b
95% CI P
Diagnosed cancer type

Hematological cancers 34 21.7

3.87 .88 to 17.07 .074
Solid or soft tissue tumors 10 31.2

6.36 1.26 to 32.08 .029
*

CNS or brain tumors 2 6.7

1.00 Reference
Cancer recurrence

Yes 9 29.0

1.72 .73 to 4.04 .217
No 36 19.3

1.00 Reference
Age at diagnosis

Early childhood (≤ 5)
13 25.5

1.00 Reference
School age (6 – 12) 15 16.9

.59 .26 to 1.37 .222
Adolescence (13 – 17) 17 23.9

.92 .40 to 2.12 .845
Time since diagnosis

< 10 years 16 19.0

1.00 Reference
10 – 14 years 5 8.1

.37 .13 to 1.08 .069
15 – 19 years 11 28.2

1.67 .69 to 4.05 .256
≥ 20 years 13 50.0

4.25 1.66 to 10.90 .003
**

CI = Confidence Interval; OR = Odds Ratio; CNS = Central Nervous System.
Note. Observed frequencies and percentages within each sociodemographic
characteristics were reported.
a
This group represents the survivors that exceeded a T
score of 63 for the Global Severity Index.
b
OR = Odds ratio for being classified as
having a significant level of psychological distress.
*
p < .05.
**
p < .01.

62
Table 9
Multivariate Logistic Regression Analysis of Psychological Distress (n = 223)
Variable OR
a
95% CI
Perceived physical functioning .92
**
.86 to .98
Perceived public stigma 1.25
**
1.09 to 1.45
Age
Adolescent (15 – 18) Reference
Emerging adult (19 – 25) 4.04
*
1.12 to 14.50
Young adult (26 – 39) 3.84 .72 to 20.47
Economic status
Stable Reference
Unstable 2.28 .94 to 5.53
Diagnosed cancer type
Hematological cancers 10.60
*
1.08 to 104.45
Solid or soft tissue tumors 27.50 2.39 to 316.19
CNS or brain tumors Reference
Time since diagnosis
< 10 years Reference
10 – 14 years .34 .10 to 1.12
15 – 19 years 2.09 .66 to 6.64
≥ 20 years 2.19 .53 to 9.03
CI = Confidence Interval; OR = Odds Ratio; CNS = Central Nervous System.
Note.
a
OR = Odds ratio for being classified as having a significant level of psychological
distress.
*
p < .05.
**
p < .01.

63
Results for Research Aim 3
Aim 3 examined mediated effects of perceived physical functioning and perceived
public stigma on psychological distress through the multiple mediators of self-stigma,
self-disclosure, and perceived availability of social support. As a first step, the fit of the
measurement model was tested and then the structural model with theoretically derived
direct and indirect paths was tested in the second step. Finally, total and specific indirect
effects of perceived physical functioning and perceived public stigma on psychological
distress were examined.
Testing a measurement model. The fit of the measurement model for two latent
variables (perceived public stigma and perceived availability of social support) was tested
using the confirmatory factor analysis (CFA), and the fit statistics and significance of
parameter estimates were examined. Table 10 shows the correlations among the twelve
observed variables included in the model and Table 11 presents the factor loadings for the
measurement model from CFA of the perceived public stigma and perceived availability
of social support. The results of the CFA indicated that the measurement model exhibited
an adequate fit to the data, χ
2
(12)

= 13.835, CFI = .997, TLI = .995, RMSEA = .026, 90%
CI = .000 to .076. All individual factor loadings were significant and were moderate to
high in magnitude; loadings for perceived public stigma ranged from .61 to .79 (p < .001)
and loadings for social support availability ranged from .59 to .95 (p < .001). The
dimension of support (emotional-informational support and positive social interaction)
tap similar properties and a correlated error between them was justified. The correlation
between two latent factors was -0.646.

64
Table 10
Bivariate Correlations among Observed Variables (n = 223)
1 2 3 4 5 6 7 8 9 10 11 12
1. Physical functioning _
2. Public stigma Parcel 1 -.26
***
_
3. Public stigma Parcel 2 -.26
***
.63
***
_
4. Public stigma Parcel 3 -.19
**
.50
***
.48
***
_
5. Social support (EI) .25
***
-.13 -.23
**
-.06 _
6. Social support (T) .22
**
-.11 -.18
**
-.12 .46
***
_
7. Social support (A) .21
**
-.13 -.21
**
-.07 .55
***
.70
***
_
8. Social support (P) .23
**
-.14
*
-.27
***
-.09 .68
***
.60
***
.79
***
_
9. Self-stigma: Shame -.10 .43
***
.54
***
.41
***
-.16
*
-.13 -.16
*
-.15
*
_
10. Self-stigma: Self-blame -.09 .32
***
.32
***
.07 -.08 -.17
*
-.12 -.10 .27
***
_
11. Self-disclosure -.02 -.08 -.16
*
-.04 .23
***
.12 .22
**
.22
***
-.45
***
-.04 _
12. Distress -.29
***
.22
**
.25
***
.20
**
-.30
***
-.18
**
-.22
**
-.35
***
.28
***
.10 .00 _
Notes. Public Stigma 1, 2, 3 = the three parcels created for Public Stigma; Shame and Self-blame = the two dimensional
indicators for Self-Stigma; Social support (EI), (T), (A), (P) = the four parcels created from the each subscale of the MOS-SS.
T = tangible support; EI = emotional-informational support; A = affectionate support; P = positive social interaction support.
*
p < .05.
**
p < .01.
***
p < .001.

65
Table 11
Factor Loadings for the Measurement Model (n = 223)
Measured variable
Unstandardized
factor loading
Standardized
factor loading
Z
Public stigma
Public stigma Parcel 1 1.00 0.61 11.61
***

Public stigma Parcel 2 1.90 0.79 16.57
***

Public stigma Parcel 3 1.80 0.79 16.66
***

Social support availability
Emotional/informational support 1.00 0.59 11.88
***

Tangible support 0.63 0.74 21.02
***

Affectionate support 0.65 0.95 40.80
***

Positive social interaction 0.56 0.83 29.19
***

***
p < .001.

Testing a structural model. After building a measurement model with adequate
fit, a structural model was tested to examine the hypothesized relationships among the
study variables. The fit indices generated for a hypothesized model are presented in Table
12. These indices indicate a good fit of the model to the data, yielding an overall χ
2
(44)
value of 79.47 (CFI = .963; TLI = .944, SRMR = .055; RMSEA = .060, 90% CI = .038
to .081). In the tested model, a ratio of χ
2
to the df was 1.81 (less than a value of 3),
indicating a good model fit. The hypotheses were then tested by examining the
significance of the path coefficients and standardized coefficients of each pathway as

66
shown in Figure 2. The significant paths were partially consistent with the hypothesized
model. The results indicated that perceived physical functioning positively predicted
social support availability (β = .192, p < .05), which, in turn, negatively predicted
psychological distress (β = –.220, p < .01). There was significant negative direct effect
from perceived physical functioning to psychological distress (β = –.185, p < .01).
Perceived public stigma was positively related to self-stigma, both internalized shame (β
= .571, p < .001) and self-blame (β = .372, p < .001), whereas self-disclosure was
negatively related to internalized shame (β = –.361, p < .001), but not self-blame (Path a
in Figure 2). Internalized shame positively contributed to psychological distress (β = .271,
p < .01), but there was no significant relationship between self-blame and psychological
distress (Path b in Figure 2). Perceived public stigma also negatively predicted self-
disclosure (β = –.148, p < .05) and social support availability (β = –.186, p < .05) which
differently contributed to psychological distress (self-disclosure, β = –.220, p < .01; social
support availability, β = .171, p < .05). There was no significant direct effect of perceived
public stigma on psychological distress (Path c in Figure 2)

Table 12
Fit Indices for Hypothesized Structural Model
Model CFI TLI SRMR RMSEA 90% CI χ
2
df
Hypothesized model .963 .944 .055 .060 .038, .081 79.47 44
CFI = Comparative Fit Index; TLI = Tucker-Lewis Index; SRMR = Standardized Root-
Mean-Square Residual; RMSEA = Root-Mean-Square Error of Approximation; CI =
Confidence Interval.

67
Self-Disclosure
Psychological
Distress
Physical
Functioning
Public Stigma
Internalized
Shame
Self-Blame
Social Support
Availability
e
e
e
e
EI T A P
P1 P2 P3
e e e e
e
e e
e

Figure.2. Structural Model for Mediation of Perceived Physical Functioning and
Perceived Public Stigma Effects on Psychological Distress

Note. Dash lines indicate non-significant paths.
–.220
**
.192
*

–.186
*

–.361
***

.372
***

–.148
**

–.185
**

.271
**
.571
***

.171
*

a
b
c

68
Testing the significance of indirect effects. Table 13 shows the statistical
significance of the mediated effects of perceived physical functioning and perceived
public stigma on psychological distress. The relative strength of the total as well as the
specific indirect effects, together with their 95% bias-corrected (BC) bootstrap
confidence intervals (CI) is also given in Table 13. In support of hypothesis 3a, the
indirect effect of perceived physical functioning on psychological distress through the
mediator of social support availability was significant at the .05 level as the 95% BC
bootstrap CI for the indirect effects did not include zero (B = –.059, 95% CI = –.15 to –
.01).
The analysis yielded a significant total indirect effect of perceived public stigma
on psychological distress through three mediators (B = 2.720, 95% CI = .67 to 5.40),
supporting hypothesis 3b. More specifically, the indirect effects of perceived public
stigma on psychological distress through internalized shame (B = 2.417, 95% CI = .72 to
4.69) and social support availability (B = .638, 95% CI = .09 to 2.12) were significant.
Although self-disclosure alone was not a significant mediator, the indirect effects of
perceived public stigma on psychological distress through a chain of two mediators- self-
disclosure and internalized shame- was significant (B = .227, 95% CI = .01 to .65). Both
self-blame nor a chain of self-disclosure and self-blame did not significantly mediate the
effects of perceived public stigma on psychological distress.

69
Table 13
Indirect Effect Estimates through Self-Stigma, Self-Disclosure, and Social Support Availability (n = 223)
Independent
variable
Mediator
variable
Dependent
variable
Estimate (95% CI)
a

Total indirect effect of perceived physical functioning on distress -.059 (–.152, –.012)
*

Physical functioning → Social support availability → Distress -.059 (–.152, –.012)
*

Total indirect effect of perceived public stigma on distress 2.720 (.667, 5.404)
*

Public stigma → Internalized shame → Distress 2.417 (.721, 4.689)
*

Public stigma → Self-blame → Distress –.167 (–.992, .680)
Public stigma → Self-disclosure → Distress –.397 (–1.563, .000)
Public stigma → Self-disclosure → Internalized shame → Distress .227 (.011, .652)
*

Public stigma → Self-disclosure → Self-blame → Distress .001 (–.011, .042)
Public stigma → Social support availability → Distress .638 (.094, 2.117)
*

CI = Confidence Interval.
Note. Each indirect effect was estimated as the product of the two component path coefficients. Numbers in parentheses
represent 95% bias-corrected bootstrap confidence intervals.
*
This 95% confidence interval excludes zero and therefore is significant at p < .05.

70
Results for Research Aim 4
Aim 4 examined gender differences within the mediated effects of perceived
physical functioning and perceived public stigma on psychological distress in childhood
cancer survivors. Prior to the main analyses, the major study variables were compared by
gender to examine possible differences. Then, the multiple mediation model was
separately tested for male and female survivors. Specifically, the total and specific
indirect effects of perceived physical functioning and perceived public stigma on
psychological distress were examined.
Gender differences in reported variables. Table 14 provides mean scores and
standard deviations of major study variables by gender. The results based on independent
sample t-tests demonstrated that the average levels of psychological distress differed by
gender (t = 2.171, df = 212, p < .05). Female survivors reported a significantly higher
mean GSI score (M = 56.45, SD = 8.23) than that of male survivors (M = 53.83, SD =
9.63). Although female survivors reported higher levels of availability in all four domains
of social support than male survivors, only the mean score of emotional-informational
support availability was significantly different (t = 2.347, df = 218, p < .05), indicating
higher availability of emotional-informational support among female survivors (M = 3.93,
SD = .89) than male survivors (M = 3.62, SD = 1.01). The levels of perceived physical
functioning, perceived public stigma, self stigma (internalized shame and self-blame),
and self-disclosure did not differ by gender.

71
Table 14
Descriptive Statistics for Main Study Variables by Gender (n = 223)

Male
(n = 132)

Female
(n = 90)

Variable Mean SD Mean SD t-value df
Psychological distress
a
53.83 9.63 56.45 8.23 2.171
*
212
Perceived physical functioning 52.77 6.34 52.73 7.08 –.048 218
Perceived public stigma 1.97 .65 1.93 .61 –.481 218
Self-stigma: Internalized shame 3.77 1.91 3.96 1.66 .756 217
Self-stigma: Self-blame 1.92 .965 1.84 .885 –.629 219
Self-disclosure 3.72 1.56 3.96 1.51 1.121 216
Social support availability
Emotional-Informational support 3.62 1.01 3.93 .89 2.347
*
218
Tangible support 3.98 1.03 4.14 .89 1.253 219
Affectionate support 4.10 1.11 4.30 .93 1.396 219
Positive social interaction 3.94 1.05 4.15 .95 1.500 217

a
Equal variance not assumed.
*
p < .05.

72
Testing a structural model for male and female survivors. The hypothesized
structural model was tested separately for male and female survivors and the fit indices
for the model are presented in Table 15. These indices yield an overall χ
2
(44) value of
75.53 (CFI = .951; TLI = .926, SRMR = .077; RMSEA = .074, 90% CI = .044 to .102)
for male survivors and χ
2
(44) value of 64.17 (CFI = .941; TLI = .911, SRMR = .072;
RMSEA = .071, 90% CI = .026 to .106) for female survivors. In the tested model, a ratio
of χ
2
to the degrees of freedom was 1.71 for male and 1.46 for female (less than a value
of 3), indicating an acceptable model fit to the data for both male and female survivors.

Table 15
Fit Indices for Hypothesized Structural Models across Gender
Model CFI TLI SRMR RMSEA 90% CI χ
2
df
Male survivors .951 .926 .077 .074 .044, .102 75.532 44
Female survivors .941 .911 .072 .071 .026, .106 64.170 44
CFI = Comparative Fit Index; TLI = Tucker-Lewis Index; SRMR = Standardized Root-
Mean-Square Residual; RMSEA = Root-Mean-Square Error of Approximation; CI =
Confidence Interval.

73
Testing the significance of indirect effects for male and female survivors.
Tables 16 and 17 contain the statistical significance of the hypothesized mediated effects
of perceived physical functioning and perceived public stigma on psychological distress
for male and female survivors. Unexpectedly, an examination of the 95% BC bootstrap
CI for the total indirect effects showed that the effect of perceived physical functioning
on psychological distress as mediated through social support availability was not
significant for male and female survivors. As hypothesized, the mediated effects of
perceived public stigma on psychological distress were found to be different for male and
female survivors. The total as well as specific indirect effects of perceived public stigma
on psychological distress were not significant for male survivors. In contrast, the total
indirect effects of perceived public stigma on psychological distress were statistically
significant for female survivors. Specifically, internalized shame (B = 2.832, 95% CI
= .612 to 7.216) and social support availability (B = 2.035, 95% CI = .156 to 6.541)
significantly mediated the impact of perceived public stigma on psychological distress for
female survivors. For female survivors, self-disclosure alone was not a significant
mediator; however, the chain of two mediators- self-disclosure and internalized shame
significantly mediated the relationship between perceived public stigma and
psychological distress (B = .591, 95% CI = .032 to 2.061). Self-blame alone and a chain
of self-disclosure and self-blame were not significant mediators for female survivors.

74
Table 16
Indirect Effect Estimates through Self-Stigma, Self-Disclosure, and Social Support Availability (Male Survivors) (n = 132)
Independent
variable
Mediator
variable
Dependent
variable
95% CI
b

Total indirect effect of perceived physical functioning on distress –.108 (–.302, .011)
Physical functioning→ Social support availability → Distress –.108 (–.302, .011)
Total indirect effect of perceived public stigma on distress 1.199 (–1.518, 4.580)
Public stigma → Internalized shame → Distress 1.517 (–1.062, 4.253)
Public stigma → Self-blame → Distress –.367 (–1.990, .744)
Public stigma → Self-disclosure → Distress –.087 (–1.078, .228)
Public stigma → Self-disclosure → Internalized shame → Distress .060 (–.080, .516)
Public stigma → Self-disclosure → Self-blame → Distress –.001 (–.085, .013)
Public stigma → Social support availability → Distress 077 (–.748, 1.412)

CI = Confidence Interval.
Note. Each indirect effect was estimated as the product of the two component path coefficients. Numbers in parentheses
represent 95% bias-corrected bootstrap confidence intervals.
*
This 95% confidence interval excludes zero and therefore is significant at p < .05.

75
Table 17
Indirect Effect Estimates through Self-Stigma, Self-Disclosure, and Social Support Availability (Female Survivors) (n = 90)
Independent
variable
Mediator
variable
Dependent
variable
95% CI
b

Total indirect effect of perceived physical functioning on distress .016 (–.070, .125)
Physical functioning → Social support availability → Distress .016 (–.070, .125)
Total indirect effect of perceived public stigma on distress 4.479 (1.274, 10.529)
*

Public stigma → Internalized shame → Distress 2.832 (.612, 7.216)
*

Public stigma → Self-blame → Distress –.016 (–1.569, 1.006)
Public stigma → Self-disclosure → Distress –.963 (–3.636, .079)
Public stigma → Self-disclosure → Internalized shame → Distress .591 (.032, 2.061)
*

Public stigma → Self-disclosure → Self-blame → Distress .001 (–.102, .155)
Public stigma → Social support availability → Distress 2.035 (.156, 6.541)
*

CI = Confidence Interval.
Note. The bias-corrected bootstrap confidence intervals are reported in this table.
a
standardized indirect effect.
b
These values
were based on unstandardized path coefficients.
*
This 95% confidence interval excludes zero and therefore is significant at p < .05.

76
CHAPTER 6: DISCUSSION
Research Aim 1 examined overall prevalence of psychological distress in Korean
adolescent and young adult (AYA) cancer survivors and compared their characteristics
with and without significant levels of psychological distress using t-tests and chi-square
tests. Research Aim 2 identified salient risk factors (i.e., perceived physical functioning
and perceived public stigma) for psychological distress using logistic regression analyses.
Research Aim 3 examined the mediated effects of perceived physical functioning and
perceived public stigma on psychological distress through self-stigma, self-disclosure,
and social support availability, using structural equation modeling (SEM) with
bootstrapping samples. Research Aim 4 examined gender differences within the mediated
effects of perceived physical functioning and perceived public stigma through the
mediators using SEM with bootstrapping samples. The following sections present
specific findings and implications for each research aim, followed by limitations and
overall strengths of the study.
Research Aim 1
In this study, one fifth of the survivors (20.6%) reported significant levels of
psychological distress. Higher proportions of both male and female survivors were
classified as psychologically distressed (18.5% of males and 23.9% of females) compared
to the US norm population (10% of males and females) and compared to survivors (8.6%
of males and 12.4% of females) from the US Childhood Cancer Survivor Study (Zeltzer
et al., 2008). Korean cancer survivors had a higher mean GSI score (M = 54.9) compared
to the average levels of psychological distress among the US norm population group (M

77
= 50) and a study of US survivors (M = 49.2) (Zeltzer et al., 2008).
A higher prevalence of psychological distress among Korean childhood cancer
survivors may reflect cross-national differences in prevalence of distress (Simon,
Goldberg, Von Korff, & Ustün, 2002). Choa, Namb, and Suh (1998) found higher rates
of depressive symptoms in a nationwide sample of Korean adults than in most studies
describing U.S. populations. Sociocultural factors, such as intense competition for limited
resources in Korean society, may partially explain the higher rates of psychological
distress among AYA cancer survivors in Korea. For example, the enrollment rate in
higher education among Koreans is one of the highest in the world and the education
system is hierarchically structured (Kim & Lee, 2006). Such an environment may lead to
Korean adolescents’ and young adults’ stress due to educational competition. Considering
the reported difficulties among childhood cancer survivors with school attendance,
reentry, and peer relationships, during and after treatment (Kim & Yi, 2012), Korean
AYA survivors are likely to face double the challenges in achieving expected levels of
education.
Cancer experience may have both negative as well as positive impact on
psychological health of cancer survivors. It was found that people who experience
traumatic events report both negative and positive effects (Aldwin, 2007; Joseph,
Williams, & Yule, 1993; Tedeschi & Calhoun, 1996). Individuals often experience
positive changes after traumatic experiences, referred to as post-traumatic growth (PTG)
(Tedeschi & Calhoun, 1995; 2004). A wide range of cancer survivors reported positive
life changes and personal growth after their cancer diagnosis (for a review, see Stanton,

78
Bower, & Low, 2006). This study only examined the negative impact of cancer; therefore,
future research should explore both positive and negative impact of cancer on the
psychological well-being of cancer survivors.
This study provides a comparative profile of AYA childhood cancer survivors
with and without significant levels of psychological distress. Relatively higher
proportions of distressed survivors were represented among those with who were older,
had unstable economic status, and had a longer time since diagnosis. Different profiles
between distressed and non-distressed survivors and possible explanations are further
discussed in the following discussion of Research Aim 3. Survivors with and without
distress also differed in their cognitive and social outcomes, indicating the importance of
such factors that may differently affect psychological distress among cancer survivors.
Compared with non-distressed survivors, distressed survivors reported significantly lower
levels of physical functioning and higher levels of public stigma and social support
availability. Distressed survivors reported significantly higher levels of internalized
shame in relation to disclosure of one’s cancer history, but not self-blame pertaining to
who or what is responsible for the cancer diagnosis. Such findings may indicate different
roles for specific dimensions of self-stigma in relation to psychological distress among
AYA cancer survivors. Although both are internalized reactions to stigma, self-blame is
defined as the attribution of undesirable events to one's behavior or stable aspects of the
self (character) (Janoff-Bulman, 1979), whereas shame is related to ‘negative emotion
elicited when a person experiences failure in relation to personal or social standards’
(Fortenberry et al., 2002, p. 378). Research Aim 3 addresses how two dimensions of self-

79
stigma (internalized shame and self-blame) contribute differently to psychological
distress.
Clinical implications. These findings indicate a greater need for monitoring and
follow-up care related to psychological health during and after treatment for childhood
cancer. In general, it is difficult to provide cancer survivors with follow-up care and
referrals for psychosocial services because they are hard to reach once cancer treatment
ends (Gurney et al., 2009). Given that less than 20% of adult survivors of childhood
cancer receive follow-up care (Oeffinger et al., 2004), it is important that cancer
treatment plans address aftercare needs for both primary care and mental health specialty
care. In Korea in particular, there is a lack of psychological counseling and related
services for cancer survivors, despite great service needs in this population. AYA
childhood cancer survivors in Korea reported a wide range of psychological challenges,
including academic difficulties, worries about marriage and fertility issues, fear about
cancer recurrence, and public stigma towards cancer survivors (Kim & Yi, 2012).
Understanding the profile of Korean cancer survivors with significant levels of
psychological distress in comparison to those without distress may help in developing
outreach strategies targeting those at-risk for psychological distress. Outreach and
collaboration with health care professionals to increase mental health referrals could
provide opportunities to address this growing need for psychological support among
childhood cancer survivors.

80
Research Aim 2
This study provides information about significant correlates of psychological
distress. Specifically, Aim 2 identified common risk factors as well as possible salient
risk factors for psychological distress resulting from cancer experiences in cancer
survivors. Consistent with prior investigations of general populations (Ettner, 1996) as
well as cancer survivor populations (Kaiser, Hartoonian, & Owen, 2010; Michel et al.,
2010; Zebrak et al., 2002), sociodemographic characteristics, such as older ages and
unstable economic status, added to the risk factors for survivors’ psychological distress.
These findings should be interpreted as the perceived economic status of the participants’
household rather than their objective individual economic achievements, as many of the
participants were adolescents and emerging adults who have yet to enter the workforce.
Consistent with previous findings (Schultz et al., 2007; Zebrak et al., 2007),
cancer type was found to be a significant correlate of psychological distress. Specifically,
it was found that those diagnosed with solid or soft tissue tumors were at higher risk for
having significant distress than those diagnosed with central nervous system (CNS) or
brain tumors. This may have to do with different levels of treatment intensity (e.g.,
chemotherapy, radiation therapy, or surgical intervention) (Kazak et al., 2010; Zeltzer et
al., 2008). Although the time since diagnosis or end of treatment was not associated with
psychological outcomes in other studies (Gray et al., 1992; Zebrak et al., 2002), longer
time since diagnosis was associated with significant distress in this study. This may
reflect possible physical and psychological effects that emerge long after treatment ends,
subsequently affecting levels of psychological distress. The significance of time since

81
diagnosis may also result from the strong association between psychological distress and
age.
Some findings were inconsistent with existing knowledge. Other
sociodemographic characteristics, such as marital status, educational level, and
employment status, were found to be associated with distress in other studies of
childhood cancer survivors (Zeltzer et al., 2009); this was not the case with our sample.
These variables were less applicable in the current study, since a significant portion of the
participants were young, unmarried, still in school, and had yet to enter the workforce.
Also, in contrast to other studies that found that gender (Michel, et al., 2010; Zebrack et
al., 2007; Zeltzer et al., 2009), age at diagnosis (Kazak et al., 2010; Michel et al., 2010),
and cancer recurrence (Elkin et al., 1997) were correlates for psychological distress, no
such associations were found among Korean cancer survivors.
The most powerful finding for Aim 2 was that perceived poor physical
functioning and higher levels of perceived public stigma were associated with an
increasing likelihood of having significant levels of psychological distress, controlling for
significant sociodemographic and cancer-related correlates. This finding is consistent
with the several studies that found poor self-rated health (Kaiser et al., 2010; Zebrak et al.,
2007) as a salient risk factor for distress in cancer survivors. It is reported that
approximately half of young adult survivors of childhood cancer have poorer health
status after than before cancer diagnosis and treatment (Hudson et al., 2003). Perhaps, the
survivors with such poor physical functioning have limited opportunities for education,
employment and marital satisfaction, thereby contributing to survivors’ psychological

82
distress. Consistent with the findings of a positive association between public stigma and
psychological distress (Else-Quest et al., 2009; Gonzalez & Jacobsen, 2011; Phelan et al.,
2011), public stigma may be particularly distressing in Korean cancer survivors due to
the negative cultural milieu toward cancer patients and survivors in Korean society. A
national survey conducted in Korea by Cho et al. (2012) has shown that over 70% of
respondents agreed that cancer patients would not be able to make contributions to
society and about 30% answered that they would avoid interacting with cancer survivors
in their neighborhood or community. Such findings reflect the tremendous impact of
public stigma as a critical source of psychological distress among Korean cancer
survivors.
Clinical implications. These findings provide further empirical evidence of
salient risk factors associated with psychological distress. Developing a greater
understanding of risk factors for psychological distress can help explain different levels
of distress in cancer survivors and can inform community-based preventions and
intervention strategies that address those risk factors. An emphasis must be given to
regular follow-up care to improve physical functioning which also promotes earlier
identification of psychological distress in cancer survivors. Despite the fact that late
effects and chronic illness following cancer treatments have been increasing among
childhood cancer survivors (Oeffinger et al., 2006) awareness about the importance of
comprehensive long-term follow-up care for pediatric cancer survivors has been limited.
Establishing such programs is necessary to provide health care for survivors with mental
health needs, screening for late effects, and education for risk reduction and promotion of

83
healthy lifestyles (Aziz, Oeffinger, Brooks, & Turoff, 2006).
Findings also indicate a need for refinement of interventions that reduce stigma
towards cancer patients and survivors and increase awareness of cancer at the societal and
individual level. Most Koreans receive little formal education on cancer issues and a lack
of knowledge about cancer itself enhances that cancer-related public stigma. Stigma is
also a critical barrier for those affected by cancer to seek services (Holland, Kelly, &
Weinberger, 2010). Since public stigma strongly embedded in society is not easily
eliminated, consistent efforts in education are needed to reduce cancer-related stigma
affecting the survivors’ psychological distress as well as to improve utilization of mental
health services among cancer survivors.
Research Aim 3
Aim 3 provides an understanding of the ways perceived physical functioning and
perceived public stigma influence one’s psychological distress among AYA childhood
cancer survivors in Korea. Specifically, the findings indicated a significant mediated
effect of perceived physical functioning on psychological distress through perceived
availability of social support. These findings highlighted the protective role of perceived
availability of social support by diminishing the negative effects of poor physical
functioning on their level of psychological distress. Such a buffering role of social
support availability is critical among childhood cancer survivors who often face limited
physical functioning resulting from common late effects of cancer treatment (Oeffinger,
Eshelman, Tomlinson, Buchanan, & Foster, 2000).
The results also indicated a significant mediated effect of perceived public stigma

84
on psychological distress through multiple mediators. However, no direct effects were
found between perceived public stigma and psychological distress. Specifically, social
support availability was found to be a significant mediator, confirming a stress-buffering
role. Although, self-disclosure was not found to be a significant mediator, the direct
relationship with self-disclosure should be emphasized. More specifically, perceived
public stigma negatively predicted level of self-disclosure, which is consistent with prior
findings from a recent study of a national sample of Koreans (Cho et al., 2012). In their
study, about 50% of participants responded that they would not disclose a cancer
diagnosis to others, showing a cultural taboo about disclosure of cancer history and
sharing survivors’ experiences. Furthermore, the finding of higher levels of self-
disclosure about cancer experiences being associated with higher levels of psychological
distress was unexpected. This may have to do with the idea of a different cognitive
process depending on how others respond to the disclosure (Lepore, 2001; Rime,
Mesquita, Philippot, & Boca, 1992). Individuals may benefit from disclosing their
experiences when they perceive supportive responses from others. Such responses may
help the person learn to tolerate negative emotions and support effective coping
(Pennebaker, 1989). In contrast, sharing their experiences may accelerate distress when
they perceive others respond to them in ways that are hostile (Manne, Alfieri, Taylor &
Dougherty, 1999). Hamilton and Zebrak (2011) illustrated the situations that are often
upsetting to cancer survivors when talking about their experiences with dating partners.
For example, partners may mention someone they know who did not survive cancer or
minimize the importance of cancer when responding to the survivors (Hamilton & Zebrak,

85
2011). Therefore, self-disclosure about the cancer experience may buffer or accelerate
distress depending on the situation and the way others respond. Given the cultural stigma
towards cancer in Korean society, it is not surprising that unfavorable public responses to
the cancer experiences are distressing to survivors. Future studies could investigate
differential levels of disclosure across various social networks and the resultant different
effects on their psychological distress.
Although self-disclosure alone was not a significant mediator, the mediated
effects of perceived public stigma on psychological distress was significant when it was
through a chain of two mediators - self-disclosure and internalized shame. Perceived
public stigma negatively predicted self-disclosure, and self-disclosure negatively
predicted internalized shame, which, in turn, positively predicted psychological distress.
Such a chain of mediators leading to psychological distress highlights the importance of
self-disclosure indirectly affecting one’s psychological distress.
Interestingly, internalized shame and self-blame had different effects on the links
between perceived public stigma and psychological distress. Internalized shame was
found to be a significant mediator between perceived public stigma and psychological
distress, supporting the modified labeling theory (Link et al., 1989). In contrast to the
significant mediating roles of internalized shame, the mediating effects of self-blame
were not significant. These findings add to the theory by showing that different
dimensions of self-stigma play a different role in the mediating relationship with
psychological distress. Similarly, Tangney and Dearing (2002) found that shame had a
stronger effect on psychological distress than guilt even though both showed an

86
association with psychological distress. Although the path was not significant, there were
negative trends between self-blame and psychological distress which seems counter-
intuitive. Such negative trends with psychological distress contradict previous findings
that self-blame was negatively correlated with adjustment in cancer patients (Berckman
& Austin, 1993). This may be related to differential pathways of psychological distress
depending on how survivors use self-blame in coping with illness. Janoff-Bulman (1979)
defined two types of self-blame, characterological and behavioral self-blame.
Characterological self-blame involves “attributions to a relatively non-modifiable source,
and is associated with a belief in personal deservingness for past negative outcomes”,
thereby resulting in maladaptive outcomes (Janoff-Bulman, 1979, p. 1798). In contrast,
behavioral self-blame involves “attributions to a modifiable source, and is associated with
a belief in the future avoidability of a negative outcome” (Janoff-Bulman, 1979, p. 1798).
Therefore, behavioral self-blame may lead to less maladaptive outcomes (Janoff-Bulman,
1979). Future studies are needed to examine the effects of the two different dimensions of
self-blame as these could differentially contribute to survivors’ quality of life.
Clinical implications. Understanding the mediated effects of perceived physical
functioning and perceived public stigma on psychological distress helps develop
interventions designed to improve psychological health in cancer survivors. As a long-
term goal, tremendous efforts are being made to improve physical functioning and reduce
public stigma towards cancer at a societal level. Although such efforts have been
underway, it is difficult to successfully achieve this ultimate goal in a short time period.
Thus, the findings inform intervention targeting identifiable and modifiable cognitive and

87
social factors for AYA cancer survivors. Such interventions may target the reinforcement
of perceived availability of social support as well as the alleviation of internalized stigma.
Furthermore, self-disclosure could be used to help the survivors feel less internalized
shame. The intervention could provide supportive environments for sharing thoughts and
feelings about the cancer experiences, focusing on reducing internalized shame, which
ultimately leads to psychological well-being. Since many Korean AYA survivors may not
yet be comfortable disclosing their cancer diagnosis, providing support groups with peer
cancer survivors who share their positive experiences following their cancer diagnosis
could be one useful strategy. Clinicians may not recognize self-blame that may be
utilized as an adaptive coping mechanism in cancer survivors. Appropriate interventions
should involve changing the survivors’ maladaptive coping patterns as well as forming
adaptive coping skills for better adjustment.
Research Aim 4
Aim 4 found gender differences in the mediating effects of cognitive and social
factors. Although the mediated effects of perceived physical functioning on psychological
distress through social support availability were significant for all the subjects, such
mediated effects did not remain significant for both male and female survivors. These
findings may be the result of the strong direct effect of physical functioning on
psychological distress in cancer survivors. Cancer is viewed as a chronic illness which
needs physical monitoring for one’s lifetime (. Therefore, it is not surprising that
perceived physical health is the most critical source of distress among people with
chronic illnesses such as cancer. The degree to which cancer survivors are impacted by

88
cognitive and social mediators varies; therefore, future studies are needed to explore other
possible factors that influence psychological distress.
The mediated effects of perceived public stigma on psychological distress through
internalized shame, social support availability, and a chain of self-disclosure and
internalized shame were significant only in female survivors, indicating a need for
examination of the different contributions of mediators by gender. These results show
that females are more likely to utilize various resources to cope with their stressors,
indicating the importance of cognitive and social factors for interventions especially in
female survivors. Female survivors appeared to communicate less often about their
cancer experiences, perceived lower levels of social support and felt greater levels of
shame when they perceived greater levels of public stigma, which increased their
psychological distress. These findings can be explained by their differential needs for
self-disclosure about illness-related issues (Kornblith, Herr, Ofman, Scher, & Holland,
1994) and social support (Ashing-Giwa, 2000; Cohen & Syme, 1985; Israel & Schurman,
1990) across gender. For example, Kornblith et al. (1994) found that female spouses
needed open discussion about illness-related feelings and problems, whereas male
spouses did not. Such a strong desire for expression about their experiences when coping
with illness for females could function as a protective factor for psychological distress.
Although gender differences in the role of self-stigma have not been well understood, it is
plausible that internalized shame has a greater impact than public stigma on Korean
female survivors.
Aim 4 provides implications for development of possible intervention programs

89
given that all subjects may not benefit from identified mediating factors in relation to
psychological distress. Given gender differences found in the mediated effects on
psychological distress, future studies could investigate simultaneous moderated mediation
to examine whether the magnitude of the indirect effect significantly changes across the
two groups. Such detailed examinations of the contributions of multiple mediators to
psychological distress may explain the inconsistent findings related to the effects of
cognitive and social factors as well as clarify the critical mediators for interventions
aimed at addressing psychological distress in cancer survivors.
Clinical implications. Considering gender differences is important when
designing psychosocial interventions for AYA cancer survivors. The above suggested
interventions targeting modifiable mediators may better apply to female cancer survivors
to alleviate the negative effects of psychological distress. Although the mediating factors
may not be as effective for male survivors as for female survivors, reducing internalized
shame, promoting sharing about cancer experiences, and increasing social support
availability are still beneficial to address their psychological distress. Rather, different
strategies could be implemented for male survivors to produce greater benefits. Gender
differences should be also reflected in the context of program implementation as well as
evaluation.
Limitations and Future Research Directions
There are several limitations to this dissertation research study that should be
considered when interpreting these findings. First, this study sample may be biased
because it only represents voluntary participants. Such a biased study sample may

90
contribute to an underestimation of the risk for psychological distress by excluding
survivors who are unwilling to participate in the study or who are having more difficulty
with psychological adjustment in their life after cancer experiences. Second, given that
this is a hard-to-reach and stigmatized population, the sample size in the study was
relatively large. However, future studies utilizing larger sample sizes are needed to
address the psychological distress of Korean AYA cancer survivors and make the
findings more generalizable to that population. Third, due to the cross-sectional study
design and possible bi-directional relations, causality between major study variables and
psychological distress should be cautiously interpreted. Future studies could benefit from
using longitudinal data that examines the relationships over time between major study
variables in relation to psychological distress. Fourth, the findings are based on
psychological distress that were experienced within the previous 7 days, making it
difficult to further examine other relevant psychological difficulties and the possibility of
changes in distress patterns across different developmental stages of cancer survivors.
Fifth, this study used US norms for the Brief Symptom Inventory-18 (BSI-18) due to a
lack of Korean norms. Although the BSI-18 measure is widely used in diverse ethnic
groups, the generalizability of US norms to the Korean population is not known. Future
studies could address this limitation by comparing the distress level of cancer survivors
with matched control groups. Sixth, the study mainly focused on the mediating effects of
cognitive and social factors, with little attention to the inter-relationships among the
mediators. Future studies are needed to explore the unstudied inter-relationship among
the multiple mediators.

91
General Contributions
There were several major strengths of this dissertation research. First, the sample
represented AYA childhood cancer survivors who had undergone treatment at various
medical institutions. Previous studies were often conducted with cancer survivors
recruited from a single institution, making it difficult to generalize results to other cancer
survivors due to a possible selection bias. Second, this study offers evidence to support
the important roles of cognitive and social factors in mediating the effects of perceived
physical functioning and perceived public stigma on psychological distress in cancer
survivors. A greater understanding of the factors influencing psychological well-being
could potentially help social workers and other professionals identify AYA childhood
cancer survivors in greater need of psychosocial services and provide them with
appropriate resources and interventions. Specifically, the findings of this dissertation
study could inform risk-adapted interventions for newly diagnosed cancer patients as well
as those risk-reducing interventions for long-term cancer survivors at risk for
psychological distress. Lastly, the dissertation study adds to the existing literature by
examining psychological distress among childhood cancer survivors in an understudied
group. This dissertation not only advances the knowledge base about Korean cancer
survivors, but informs the development of universal interventions for Korean American
and other diverse cultural groups.

92
CHAPTER 7: CONCLUSION
Approximately 20% of Korean childhood cancer survivors were at high risk for
psychological distress, indicating a greater need for follow-up care to address for
psychological health.
Perceptions of limited physical functioning and public stigma are salient risk factors
for psychological distress in adolescent and young adult cancer survivors, informing
outreach strategies targeting those at-risk for psychological distress.
Perceived social support availability could reduce psychological distress by
buffering the negative effects of perceptions of limited physical functioning and
public stigma.
Internalized shame (self-stigma) could exacerbate the negative effect of perceived
public stigma and thereby increase psychological distress.
Self-disclosure of cancer experiences could ameliorate psychological distress by
reducing internalized shame (self-stigma).
Interventions targeting cognitive and social factors to address psychological distress
may best apply to female cancer survivors.
Understanding psychological distress of Korean cancer survivors could help to
develop universal interventions for diverse cultural groups as well as culturally
tailored interventions for Asian American cancer survivors.

93
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Abstract (if available)

Abstract The overall purpose of this dissertation is to examine cognitive and social mediators of psychological distress in Korean childhood cancer survivors. The four specific research aims are (1) to examine the overall prevalence of psychological distress and to compare the profile of cancer survivors with and without significant levels of psychological distress, (2) to examine perceived physical functioning and perceived public stigma as potential risk factors for psychological distress, taking into account possible sociodemographic and cancer-related correlates, (3) to test a model of the effects of perceived physical functioning and perceived public stigma on psychological distress as mediated through three cognitive and social factors, and (4) to examine gender differences within the mediated effects of perceived physical functioning and perceived public stigma on psychological distress. ❧ Participants consisted of 223 cancer survivors diagnosed before the age of 19 years and currently residing in the community in Korea. Participants were recruited through Korean advocacy foundations and support groups for adolescent and young adult survivors of childhood cancer. Structured questionnaires were collected from June 2010 to November 2010 either by mail or email. The overall goodness of the structural model was tested and then total and specific indirect effects were tested by using bootstrap procedures in Mplus 6.12. ❧ The primary results showed an overall prevalence rate of approximately 20% for psychological distress. Perceived poorer physical functioning and higher levels of perceived public stigma were strong risk factors for psychological distress, while controlling for age, economic status, cancer type, and time since diagnosis. There was a significant mediated effect of perceived physical functioning on psychological distress through social support availability. There was also a significant mediated effect of perceived public stigma on psychological distress through internalized shame or social support availability, or through a chain of two mediators- self-disclosure and internalized shame. The mediated effect of perceived public stigma on psychological distress differed by gender. ❧ A greater understanding of the factors influencing the levels of psychological well-being could potentially help social workers and other professionals identify childhood cancer survivors in greater needs of psychosocial services and provide them with appropriate resources and interventions.

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Asset Metadata

Creator Kim, Min Ah (author)

Core Title The effects of physical functioning and public stigma on psychological distress as mediated by cognitive and social factors among Korean survivors of childhood cancer

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 07/10/2012

Defense Date 04/09/2012

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag adolescent and young adult,cancer survivors,childhood cancer,OAI-PMH Harvest,psychological distress

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Yamada, Ann Marie (committee chair), Brekke, John S. (committee member), Chou, Chih-Ping (committee member)

Creator Email minahkim.korea@gmail.com,minahkim@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-55936

Unique identifier UC11289037

Identifier usctheses-c3-55936 (legacy record id)

Legacy Identifier etd-KimMinAh-936.pdf

Dmrecord 55936

Document Type Dissertation

Rights Kim, Min Ah

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA