Body image, internalized stigma and enacted stigma predict psychological distress in women with breast cancer: A serial mediation model

Mohammadali Amini-Tehrani, Hadi Zamanian, Mona Daryaafzoon, Seyedehroja Andikolaei, Mahshid Mohebbi, Arefeh Imani, Bita Tahmasbi, Sahar Foroozanfar, Zahra Jalali

Research output: Contribution to journalArticlepeer-review

10 Citations (Scopus)


Aims: To investigate the roles of total stigma, enacted stigma, and internalized stigma in the prediction of psychological distress among breast cancer patients, and to evaluate the mediating effect of body image in this process. Design: Cross-sectional. Methods: Between Oct-2014 to May-2015, a cross-sectional study was conducted with participation of 223 patients from three cancer centres located in Tehran, Iran. The study variables were assessed using the stigma scale for chronic illnesses 8-item version (SSCI-8), body image scale (BIS), and depression anxiety stress scale (DASS-21). Structural equation modelling using MLR estimator was employed based on the two-step procedure to validate both the full measurement models and the structural models. Five models were tested to determine predictability of all stigma constructs for psychological distress, including stress, anxiety, and depression, through the mediation of body image. Three equivalent models were further examined to re-evaluate the direction of the relationships. Results: Psychological distress and body image were largely predicted by total stigma, enacted stigma, and internalized stigma. The effect of stigma on psychological distress was mediated through body image. In a serial mediation model, the significance of the pathway of enacted stigma > internalized stigma > body image > psychological distress was confirmed. The serial model in which internalized stigma precedes body image was also supported by the equivalent models. Conclusion: Stigma has been identified as a major source of psychological distress among women with breast cancer. Enacted stigma not only psychologically disturbs the patients but also triggers a chain of other identity transformations (i.e. internalization of stigma and distortion of body image), their ultimate result being a full-blown psychological distress. Impact: Both enacted and internalized stigma distorts breast cancer patients' perception of their body image, which in turn renders them psychologically distressed. The serial process of enacted stigma, internalized stigma, and body image plays an important role in perpetuating distress in these patients. To break this chain of psychological consequences and for interventions to have a greater impact on overall well-being of patients, the effect of enacted stigma on distress via the sequence of two mediators needs to be specifically targeted at each stage.

Original languageEnglish
Pages (from-to)3412-3423
Number of pages12
JournalJournal of Advanced Nursing
Issue number8
Publication statusPublished - Aug 2021
Externally publishedYes

Cite this