Published online Jun 19, 2026. doi: 10.5498/wjp.v16.i6.115742
Revised: December 4, 2025
Accepted: February 2, 2026
Published online: June 19, 2026
Processing time: 216 Days and 20.8 Hours
Body image disturbance is a common psychosocial issue among patients with breast cancer, leading to stigma that negatively impacts their psychological well-being and quality of life. Resilience and social support are the key protective factors that may buffer this relationship. Previous studies have explored these constructs separately, but little is known about their potential chain-mediating effects on the link between body image and stigma, particularly in the Chinese population with breast cancer. This study examined the association between body image and stigma among Chinese patients with breast cancer by focusing on the sequential mediating roles of resilience and social support.
To investigate the association between body image and stigma, focusing on the chain-mediating roles of resilience and social support.
A cross-sectional survey was conducted among Chinese patients with breast cancer using an electronic que
The findings indicated that body image had a significant direct effect on stigma [effect = 0.184; 95% confidence interval (CI): 0.031-0.313]. In addition to this direct effect, three significant indirect pathways were observed: (1) Resilience (effect = 0.250; 95%CI: 0.165-0.363); (2) Social support (effect = 0.129; 95%CI: 0.030-0.237); and (3) A sequential mediation pathway involving both resilience and social support (effect = 0.053; 95%CI: 0.012-0.099). The total indirect effects of the three mediation paths accounted for 43.1% of the relationship between body image and stigmatization.
Findings highlight the roles resilience and social support play in mediating the relationship between body image and stigma. Interventions enhancing these variables may reduce stigma and improve patients’ psychological well-being.
Core Tip: Body image disturbance is a prominent psychosocial concern among individuals with breast cancer and is closely associated with increased perceptions of stigma in clinical settings. This study examined whether resilience and social support function as mediating mechanisms that link body image and stigma in a sample of Chinese patients with breast cancer. Given data from a cross-sectional survey, the findings highlighted the crucial roles played by resilience and perceived social support in alleviating the negative impacts of body image disturbances. These results provide valuable insights for developing targeted interventions to strengthen patients’ psychological resources, ultimately reducing stigma and improving their overall well-being.
- Citation: He XH, Zhou B, Liu Y, Gong YW, Zheng HL. Relationship between body image and stigma among Chinese breast cancer patients: A chain mediation model. World J Psychiatry 2026; 16(6): 115742
- URL: https://www.wjgnet.com/2220-3206/full/v16/i6/115742.htm
- DOI: https://dx.doi.org/10.5498/wjp.v16.i6.115742
Breast cancer is the most prevalent malignancy among women worldwide and has a particularly high disease burden in China[1]. Advances in early detection and treatment have improved survival rates. However, many patients with breast cancer continue to face profound psychosocial challenges that extend beyond their physical health[2]. One of the most distressing issues is body image disturbance, which arises from surgery-related disfigurements, hair loss, mastectomies, or other treatment-induced changes in appearance and femininity[3]. Body image disturbance not only affects self-esteem and social interactions but is also closely linked to stigma, a negative social label that breast cancer patients may inter
Stigma refers to negative attitudes[6], stereotypes, and discriminatory behaviors directed toward individuals with an illness that can be internalized as self-stigma and can significantly affect psychological adjustment[7]. Breast cancer patients who perceive themselves as disfigured or “different” because of visible changes in their bodies may be especially vulnerable to stigmatization from society, family, or even themselves[8]. Stigma can manifest as feelings of shame, concealment, and reduced social participation, ultimately exacerbating psychological distress and hindering recovery[9].
Resilience, defined as the capacity to adapt positively and recover from adversity, is a critical psychological resource that may buffer the negative impacts of body image disturbance[10]. Patients with higher resilience are more likely to maintain optimism, effectively regulate emotions, and mobilize coping strategies when confronted with stigma and social judgment[11]. Another important factor is social support, which refers to the perceived availability of emotional, informational, and instrumental assistance from family members and friends. Strong social support networks can provide reassurance, practical help, and validation, thereby reducing feelings of stigma and improving psychosocial adjustment[12].
Although body image disturbances and stigma in patients with breast cancer have been documented[13], the psychological mechanisms underlying this relationship remain insufficiently understood. Previous studies have typically examined resilience or social support in isolation, but few have investigated their chain-mediating effects on this ass
This study’s conceptual framework is grounded in the stress-coping theory[15], which posits that stressful experiences, such as body image disturbances, may trigger maladaptive emotional and social outcomes unless moderated by psychological and social resources. According to this framework, resilience allows individuals to adapt positively to stress, while social support provides external validation and resources that reduce the impact of stigma. Drawing from previous lite
This study was conducted using an electronic questionnaire survey at a tertiary hospital in Hunan Province and its affiliated breast cancer rehabilitation support groups between March 2023 and August 2023. The inclusion criteria were as follows: (1) Confirmed diagnosis of breast cancer by pathology; (2) Age ≥ 18 years; (3) Awareness of their diagnosis and ability to read and complete the questionnaire independently; and (4) Voluntary participation with informed consent. The exclusion criteria were as follows: (1) Patients with severe mental illness or cognitive impairment that would prevent ac
The survey was distributed via Wenjuanxing, a widely used online survey platform in China. Participants were recruited using convenience sampling, with a questionnaire link shared via hospital outpatient clinics, inpatient wards, and patient support-group communication channels. Before completing the survey, all participants were informed of the study’s purpose, voluntary nature, and confidentiality of the data. Duplicate and incomplete responses were excluded from the final dataset to ensure data quality. The sample size was determined using a formula for cross-sectional studies. In a pilot study, the mean stigma score of patients with breast cancer was estimated to be 23.1 ± 5.9. Using these values, the minimum sample size was calculated as 220. The target sample size was increased by 10% to account for potentially invalid responses and non-completion, resulting in an adjusted sample size of 242. Ultimately, 298 valid questionnaires were retained from 310 participants, an effective response rate of 96.1%.
Sociodemographic characteristics: Sociodemographic characteristics included age, marital status, educational level, employment status, monthly household income, place of residence (urban/rural), cancer stage, type of surgery (mas
The Body Image After Cancer Questionnaire-Chinese version: The Body Image After Cancer Questionnaire-Chinese version (BIBCQ-C), adapted from the original BIBCQ developed by Baxter et al[16], is a validated instrument specifically designed to assess body image concerns in breast cancer survivors. The Chinese version, translated and culturally adapted by Zhang et al[17], retained the conceptual framework of the original scale while ensuring linguistic and cultural relevance for Chinese patients. The BIBCQ-C consists of 53 items divided into six dimensions: Vulnerability, body stigma, body concerns, transparency, arm concerns, and limitations. Each item is rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores reflecting greater body image disturbance. The BIBCQ-C demonstrated good psychometric properties, including strong internal consistency and construct validity, when applied to Chinese patients with breast cancer. In the present study, Cronbach’s alpha coefficient for the total scale was 0.93, in
The Stigma Scale for Chronic Illness-8: The Stigma Scale for Chronic Illness-8, a short form of the original Stigma Scale for Chronic Illness, was developed by Rao et al[18] and was used to evaluate both enacted (perceived discrimination) and internalized stigma (self-directed negative beliefs). The Chinese version includes eight items rated on a 5-point Likert scale ranging from 1 (never) to 5 (always), with higher total scores reflecting greater perceived stigma. In the present study, the Stigma Scale for Chronic Illness-8 showed excellent internal consistency with a Cronbach’s alpha of 0.90.
The Connor-Davidson Resilience Scale: The Connor-Davidson Resilience Scale, originally developed by Connor and Davidson[19] and later revised for the Chinese population by Wu et al[20], assesses resilience across three dimensions: Resilience, strength, and optimism. It contains 25 items rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), producing total scores between 25 and 125, with higher scores reflecting greater psychological resilience. The Chinese version has been widely applied in research and has shown satisfactory psychometric properties with a Cronbach’s alpha of 0.86.
The Perceived Social Support Scale: The Perceived Social Support Scale (PSSS), developed by Zimet et al[21], measures perceived support from family, friends, and significant others. The Chinese version contains 12 items divided into three dimensions (family support, friend support, and support from significant others), with responses rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). Higher scores indicate higher perceived social support. The PSSS has been widely used in psychosocial research on Chinese patients with breast cancer. In this study, the PSSS demonstrated excellent reliability, with a Cronbach’s alpha of 0.93.
All analyses were conducted using IBM Statistical Package for Social Sciences Statistics (version 26.0; IBM Corp., Armonk, NY, United States). Descriptive statistics were used to summarize the participant characteristics based on the variable distribution. Normally distributed continuous variables were presented as a mean ± SD, while categorical variables were expressed as n (%). Pearson’s correlation analysis was used to assess the associations between body image disturbance, resilience, social support, and stigma, with statistical significance defined as P < 0.05. A serial mediation analysis was performed using the PROCESS macro (model 6) in Statistical Package for Social Sciences to assess whether resilience and social support mediate the association between body image disturbance and stigma. The significance of the mediation effects was evaluated by bootstrapping with 5000 re-samples. Mediation was considered statistically significant if the bias-corrected 95% confidence interval (CI) excluded zero. This method enables the evaluation of both individual and se
Ethical approval for this study was granted by the Ethics Committee of the University of South China (No. CS2023231). The research was conducted in accordance with the ethical standards of the Declaration of Helsinki and followed all relevant institutional and national guidelines. Written informed consent was obtained from all participants prior to their enrollment in the study.
The sociodemographic characteristics of the breast cancer patients are summarized as follows: Regarding age, 85 (18.5%) were under 39 years, 132 (44.3%) were 40-59 years, and 111 (37.2%) were over 60 years. For cancer stage, 54 (18.1%) were stage I, 86 (28.9%) were stage II, 127 (42.6%) were stage III, and 31 (10.4%) were stage IV. The detailed characteristics are presented in Table 1.
| Characteristics | Variable | Frequency | Percent (%) |
| Age | ≤ 39 | 85 | 18.5 |
| 40-59 | 132 | 44.3 | |
| ≥ 60 | 111 | 37.2 | |
| Occupational status | Not working | 73 | 24.5 |
| working | 144 | 48.3 | |
| Retired | 81 | 27.2 | |
| Income | Low-income | 101 | 33.9 |
| Middle-income | 152 | 51.0 | |
| High-income | 45 | 15.1 | |
| Marital status | Married | 256 | 85.9 |
| Divorced/widowed | 42 | 14.1 | |
| Residence | Rural | 180 | 60.4 |
| Urban | 118 | 39.6 | |
| Cancer stage | Stage I | 54 | 18.1 |
| Stage II | 86 | 28.9 | |
| Stage III | 127 | 42.6 | |
| Stage IV | 31 | 10.4 |
Body image disturbances showed a significant positive correlation with stigma, whereas resilience and perceived social support were negatively correlated with body image disturbances. Resilience and social support were negatively correlated with stigma. Detailed descriptive statistics and correlations among the study variables are presented in Table 2.
Model 6 of the PROCESS macro was used to examine whether resilience and social support mediated the link between body image disturbance and stigma. The regression results are presented in Table 3. Results indicated that body image disturbance was significantly and negatively related to resilience (β = -0.33, P < 0.001), while resilience demonstrated a positive association with perceived social support (β = 0.78, P < 0.001). In addition, body image disturbance exerted a direct positive effect on stigma (β = 0.21, P < 0.001), thus confirming hypothesis 1.
| Criterion | Predictors | R | R2 | F | B | β | t | 95%CI |
| Resilience | Body image | 0.591 | 0.349 | 77.698 | -0.535 | -0.33 | -23.18 | -0.299-0.354 |
| Social support | Body image | 0.525 | 0.276 | 55.308 | -0.325 | -0.65 | -21.36 | -0.593 to 0.713 |
| Resilience | 0.550 | 0.78 | 21.20 | 0.704-0.847 | ||||
| Stigma | Body image | 0.596 | 0.355 | 68.492 | -0.434 | 0.21 | 14.80 | 0.179-0.234 |
| Resilience | 0.102 | -0.36 | -18.36 | -0.030 to 0.397 | ||||
| Social support | 0.325 | -0.88 | -27.78 | -0.818 to 0.942 |
In line with hypothesis 2, both resilience (β = -0.36, P < 0.001) and perceived social support (β = -0.88, P < 0.001) were significantly associated with lower stigma, suggesting that greater resilience and stronger support help mitigate stigmatization. Moreover, body image disturbance showed a negative relationship with social support (β = -0.65, P < 0.001), indicating an indirect pathway through resilience and social support. These results further support hypothesis 3 by confirming a significant chain mediation effect, whereby body image disturbance affects stigma sequentially via resilience and social support. The mediation framework is depicted in Figure 1, which illustrates both the direct and indirect mec
Table 4 shows that body image disturbance had a significant direct effect on stigma (effect = 0.184; 95%CI: 0.031-0.313). Significant indirect effects were observed through resilience alone (body image → resilience → stigma; effect size = 0.250; 95%CI: 0.165-0.363) and through social support alone (body image → social support → stigma; effect size = 0.129; 95%CI: 0.030-0.237). Additionally, the sequential pathway through both resilience and social support (body image → resilience → social support → stigma) showed a modest but significant mediation effect (effect = 0.053; 95%CI: 0.012-0.099). Overall, the total effect of body image disturbance on stigma, including both direct and indirect pathways, was significant (effect = 0.615; 95%CI: 0.542-0.687). These findings indicate that resilience and social support operate as independent and se
| Effect relationship | Effect size | Boot LLCI | Boot ULCI |
| Total effect | 0.615 | 0.542 | 0.687 |
| Direct effect | 0.184 | 0.031 | 0.313 |
| Total indirect effect | 0.431 | 0.307 | 0.558 |
| Body image → resilience → stigma | 0.250 | 0.165 | 0.363 |
| Body image → social support→ stigma | 0.129 | 0.030 | 0.237 |
| Body image → resilience → social support → stigma | 0.053 | 0.012 | 0.099 |
This study explored the mediating effects of resilience and perceived social support on the relationship between body image disturbance and stigma among Chinese patients with breast cancer. Our findings indicate that both resilience and social support significantly mediated this relationship, emphasizing the multifaceted psychosocial mechanisms that shape patients’ experiences of and responses to stigma following breast cancer treatment. This study found high levels of body image concerns and perceived stigma. Previous studies have reported lower stigma levels among patients with breast cancer, which may reflect differences in cultural attitudes toward illness, appearance, and social disclosure[22]. In China, traditional cultural norms often emphasize modesty and social harmony, which can lead to uncomfortable discussions of changes in appearance, body image concerns, or disease-related difficulties. These cultural values may limit patients’ opportunities for social expression and support, thereby exacerbating the perceived stigma. In contrast, Western healthcare settings often incorporate psychosocial counseling and peer support interventions, promoting open communication and reducing stigma.
Consistent with our hypotheses, resilience was found to mediate the relationship between body image disturbances and stigma. Patients with higher resilience were better able to adapt to body changes and treatment-related challenges[23], reducing the negative psychological impact of body image disturbance[24]. High resilience enabled patients to regulate their emotions, maintain self-esteem, and employ adaptive coping strategies, which in turn lowered perceived stigma[25]. This finding aligns with previous research indicating that resilience serves as a protective factor against the psychological burden associated with chronic illness and appearance-related concerns[26].
In addition to resilience, perceived social support also emerged as a significant mediator[27]. Patients who reported stronger support from family, friends, or significant others experienced lower stigma even when facing substantial body image disturbance[28]. Social support may provide emotional reassurance, practical assistance, and affirmation of self-worth, which can buffer the adverse effects of body image concerns and foster a sense of belonging and acceptance[29]. These results highlight the importance of cultivating supportive environments for breast cancer patients to reduce internalized and perceived stigma[30].
Moreover, this study identified a sequential mediating effect of resilience and social support, indicating that these factors interact to shape patients’ experiences of stigma. Specifically, higher resilience appears to enhance patients’ abilities to seek, perceive, and utilize social support, further reducing stigma. This sequential pathway underscores the dynamic interplay between internal psychological resources and external social resources by suggesting that inter
These findings have important implications for clinical practice. Interventions aimed at improving resilience, such as cognitive-behavioral therapy[31,32] or mindfulness training[33], could help patients cope better with body image changes and reduce stigma. In parallel, strengthening social support networks through family counseling, peer support groups, or community engagement may enhance patients’ perceived support and buffer against stigmatization[34]. Peer mentorship programs have shown promise in improving resilience and self-perception in patients with breast cancer. By addressing both individual coping skills and social support, healthcare providers can help patients manage psychosocial challenges associated with breast cancer more effectively, ultimately improving their quality of life and psychological well-being.
However, this study had several limitations. First, the cross-sectional nature of the study precludes causal inferences regarding the associations between body image disturbance, resilience, social support, and stigma. Longitudinal research is warranted to clarify the temporal dynamics of these variables and better elucidate their roles in patients’ long-term psychosocial adaptation. Second, the sample was recruited from hospital-based patients with breast cancer using convenience sampling, which may limit the generalizability of the findings to a broader population of patients with breast cancer in China. Third, reliance on self-reported data may introduce response bias, as patients could under-report or over-report their body image concerns, perceived social support, or stigma. Future studies should incorporate multiple data sources or objective assessments to strengthen the validity of the findings.
Using a cross-sectional survey design, this study explored the mediating effects of resilience and perceived social support on the relationship between body image disturbance and stigma among Chinese patients with breast cancer. These results indicate that resilience and social support are important mediators in the link between body image disturbance and perceived stigma. Specifically, higher resilience and stronger social support were associated with lower levels of stigma, providing valuable insights into the psychosocial processes that influence adjustment in patients with breast cancer.
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