Psychometric validation of the Stressors in Breast Cancer Scale in Greece: Evidence for a five- factor structure

Psychometric validation of the Stressors in Breast Cancer Scale in Greece: Evidence for a five- factor structure | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychometric validation of the Stressors in Breast Cancer Scale in Greece: Evidence for a five- factor structure Katerina Chotzoglou, Georgia Raftopoulou, Eirini Karakasidou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9429181/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background A breast cancer diagnosis causes significant psychological stress throughout the disease trajectory. While generic stress measures exist in Greek, validated cancer-specific stress assessment instruments are lacking. The Stressors in Breast Cancer Scale (SBCS) is a 24-item instrument assessing five stress domains: appearance/sexuality, health/daily life, interpersonal relationships, healthcare system and future worries. Given this gap in Southern European populations, this study evaluated the psychometric properties of a Greek translation of the SBCS. Methods A cross-sectional design was employed with a sample of 216 Greek women diagnosed with breast cancer. The scale's internal structure was examined through Exploratory and Confirmatory Factor Analysis (EFA, CFA). Internal consistency was assessed using Cronbach’s alpha and McDonald’s omega coefficients. Convergent validity was assessed through correlations with perceived stress and anxiety; discriminant validity was evaluated via comparison of AVE square roots with inter-factor correlations. Results The original five-factor structure was supported, demonstrating acceptable model fit (CFI = .89, RMSEA = .08). Internal consistency was high (α = .94). The SBCS-GR showed strong positive correlations with perceived stress and anxiety. Conclusions These findings provide evidence supporting the structural validity and reliability of the SBCS-GR. The instrument may serve as a clinically relevant tool for identifying multidimensional stressors in breast cancer patients in Greece. Psychometric validation Breast cancer Stress assessment Psycho-oncology Patient-reported outcomes Figures Figure 1 Background Breast cancer is the most diagnosed cancer among women worldwide, according to data from the International Agency for Research on Cancer (IARC) and the World Health Organization. By 2035, an estimated 2.94 million women worldwide will be affected by breast cancer [1]. In developed countries, one in eight women will develop breast cancer in her lifetime [2]. In Greece, 8,987 women were diagnosed in 2022, with incidence rates comparable to other European countries, though ongoing efforts in early detection and treatment remain crucial to manage and reduce mortality rates. Breast cancer predominantly affects older women, with the majority of patients over 50 years of age at diagnosis, although approximately one in five cases are diagnosed before age 50. Breast cancer in men is rare, accounting for about 1% of cases. Incidence rates vary considerably between geographical regions, with the highest rates in Western Europe and the United States, and the lowest in Africa and Asia. This variation reflects differing distributions of breast cancer risk factors across regions [1]. Intensifying public awareness programs represents a critical global health priority. Public health education that improves women's awareness of breast cancer signs and symptoms, and helps families understand the importance of early detection and treatment, can encourage medical consultation when breast cancer is first suspected and before any cancer progresses to advanced stages [3]. Stress is a multifaceted concept encompassing physical, mental, and emotional elements that cause bodily or psychological tension. More specifically, stress can be defined as "the nonspecific response of the body to any demand for change, initiating a range of physiological and psychological responses" [4]. Stress is not purely negative, as stressful situations also provide opportunities for growth and personal development [5]. Early conceptualizations of stress focused largely on bodily disruptions to homeostasis, such as temperature changes or physical injury. Contemporary stress theories concentrate on psychological and social determinants, identifying situation appraisal and perceived availability of coping resources as central factors. Stress can be classified by its intensity, temporal pattern (acute, recurrent, or chronic), and the degree of control over the stressor [6]. The diagnosis and treatment of breast cancer are extremely taxing both physically and emotionally, with treatment intensity varying by disease type and stage. Women often experience high levels of anxiety [7], diminished quality of life [8,9], elevated rates of depression [10], and post-traumatic stress [11,12]. Body image and self-esteem concerns are particularly pronounced when treatment involves mastectomy or chemotherapies that affect physical appearance [13]. Patients experience the disease as threatening, confronting anger, despair, and guilt—emotions that can be difficult to recognize, process, and express [14,15]. Moreover, follow-up appointments necessary for disease monitoring or recurrence detection generate significant anxiety, with distress peaking approximately two days before appointments, particularly regarding the possibility of recurrence [16]. Despite increasing recognition of the psychological burden associated with breast cancer, culturally adapted instruments that capture disease-specific stressors remain limited, particularly in Southern European populations. To our knowledge, no validated instrument currently exists in Greek to assess the multidimensional stress experience of breast cancer patients. This gap limits both clinical screening and research on targeted psychosocial interventions. The present study aims to address this gap by providing a culturally adapted and psychometrically validated version of the SBCS for use in Greek clinical and research settings. Methods Study design and participants This study has been authorized by the original authors to translate the English version of SBCS in Greek language and test its reliability and validity. The research protocol was submitted for approval to the Scientific Council of both the Panhellenic Association of Women with Breast Cancer “Alma Zois” and IASO Hospital 2nd Breast Clinic. Additionally, a Confidentiality form had been signed between the researcher and IASO 2nd Breast Clinic Manager in order to get access to patients’ data list and forward them the link. The sample has been selected from March, 2025 to May, 2025 using Google forms through an online interface. (Table 1 ). The link with the set of three questionnaires (SBCS, PSS-14 and STAI) as well as social, demographic and disease related variables included age, education (primary school/secondary school/high school/higher education), employment (employed/retired/unemployed), information regarding the type of surgery (Lumpectomy/Mastectomy/Bilateral mastectomy/Breast reconstruction) and Hospital (Public/Private) had been posted on the researcher's social media, the Panhellenic Association of women with Breast Cancer “Alma Zois” website. The researcher emailed women diagnosed with breast cancer, inviting them to participate in the study. The email contained a link to a secure online survey with questionnaires, along with details about the study’s objectives and procedures. It was emphasized that participation was completely voluntary and that responses would remain anonymous. To ensure completeness, the survey could only be submitted once all questions were answered, preventing any missing data. Table 1 Demographic Characteristics of the Sample (N = 216). Category Group N (%) Age Groups 18–30 3 (1.4%) 31–50 83 (38.4%) 51–70 120 (55.6%) 71–80 10 (4.6%) Education Level Junior High School 4 (1.9%) High School 46 (21.3%) Graduate 92 (42.6%) MSc/PhD 59 (27.3%) Other 15 (6.9%) Employment Status Employed 146 (67.6%) Unemployed 25 (11.6%) Retired 45 (20.8%) Type of Surgery Bilateral mastectomy 17 (7.9%) Breast reconstruction 21 (9.7%) Lumpectomy 105 (48.6%) Mastectomy 73 (33.8%) Hospital Setting Private Hospital 143 (66.2%) Public Hospital 73 (33.8%) Note. Percentages are based on valid responses. Procedure The Ethics Committee of Panteion University of Social and Political Sciences approved this study (Reg. Num. 52/10-03-2025), and we conducted it in accordance with the Declaration of Helsinki. We recruited participants through convenience sampling between March and May 2025. Working with staff from Alma Zois (the Panhellenic Association of Women with Breast Cancer) and the 2nd Breast Clinic of IASO Hospital in Athens, researchers identified women who met eligibility criteria and provided them with study information. Women who wanted to participate received an email explaining the study purpose (developing a validated Greek version of a breast cancer stress scale), the voluntary nature of their participation, how we would maintain confidentiality, and the estimated time needed (about 20 minutes). The email included a secure link to the online survey on Google Forms. Before accessing the questionnaires, women provided electronic informed consent. The survey asked about demographics, then clinical characteristics (cancer stage, type of surgery, hospital setting), and included three psychological measures: the SBCS, PSS-14, and STAI (described in the Instruments section below). We configured the survey platform to require responses to all items before submission, which eliminated missing data. All responses were collected anonymously. Translation and Cultural Adaptation We developed the Greek version of the SBCS following international guidelines for cross-cultural adaptation of psychological instruments [17]. The adaptation involved several steps: Forward translation: Two independent bilingual translators, both clinical psychologists who were native Greek speakers fluent in both Spanish and English, translated the 24 items from both the Spanish and English versions to Greek. Both translators had expertise in psycho-oncology terminology and were working in oncology clinics. They translated independently to ensure diverse linguistic expression. Synthesis: Our research team compared the two forward translations and created a Greek version. We resolved discrepancies through discussion and reached consensus on item wording. Back-translation: Two bilingual translators conducted independent back-translations. The first translator, a native Spanish speaker fluent in Greek, translated the Greek version back to Spanish. The second translator, a native English speaker fluent in Greek, translated the Greek version back to English. Neither translator had seen the original Spanish or English scales. We compared both back-translations with the original versions to verify semantic and conceptual equivalence. Expert committee review: We convened an expert committee of two clinical psychologists and two breast cancer survivors to review all translations alongside the original Spanish and English scales. The committee evaluated whether each item was semantically equivalent, culturally appropriate, and comprehensible for Greek breast cancer patients. They recommended minor modifications to improve clarity and cultural relevance while preserving the original meaning and structure. Pilot testing: We administered the Greek version to five breast cancer patients and asked for their feedback on item clarity, comprehensibility, and cultural appropriateness. Based on their input, we made final minor adjustments to enhance readability. Importantly, no items required substantial modification, suggesting good cross-cultural transferability of the stress constructs measured by the SBCS. The final Greek version maintained the original 24-item structure and 5-point Likert response format, demonstrating strong alignment with both the Spanish and English versions while being culturally and linguistically appropriate for Greek women with breast cancer. Instruments Used For the assessment of stress among breast cancer patients, proper instruments should be implemented and should be tested for validity and reliability in the specific population. Such instruments are the Perceived Stress Scale (PSS-14) and the State-Trait Anxiety Inventory (STAI) that have shown high psychometric properties in the general population. However, they cover general distress perceptions and their items do not focus on breast cancer patients. There are several other instruments to assess stress among cancer patients such as the Questionnaire on Stress in Cancer Patients (QSC-R23), the Fear of Progression Questionnaire Short Form (FoP-Q-SF) [18], the Newly Diagnosed Breast Cancer Symptoms Stress Scale (NDBCSS) [19], a tool that has been examined for its validity and the reliability in the Greek population [20]. For the current study, we used two of the most popular scales in Greece in order to standardize the Stressors in Breast Cancer Scale in a Greek sample. The first scale is the Perceived Stress Scale (PSS-14), developed by Sheldon Cohen and colleagues in 1983, which is a widely used psychological instrument designed to measure the degree to which individuals perceive their lives as stressful. Based on Lazarus’s transactional model of stress, the PSS-14 evaluates how unpredictable, uncontrollable, and overloaded respondents feel their lives are, emphasizing subjective appraisals of stressors rather than objective events. The original PSS-14 comprises 14 items assessing stress over the past month, with responses scored on a 5-point Likert scale (0 = never to 4 = very often) 7 of the questions are positive (questions 4,5,6,7,9,10,13) and are rated from 4 to 0, while the remaining 7 (1,2,3,8,11,12,14) are negative and range from 0 to 4. The total score is obtained by calculating the sum of the responses given and ranges from 0 to 56 with higher scores indicating higher levels of stress. Psychometrically, the PSS-14 demonstrates strong internal consistency, with Cronbach’s α values of 0.82–0.85 for the full scale. Subscale reliabilities are slightly lower: 0.81–0.85 for negativity and 0.72–0.83 for positivity. Test-retest reliability is moderate for state-like stress (e.g., α ≈ 0.54). Construct validity is supported by correlations with biological markers (e.g., cortisol levels) and psychological outcomes (e.g., anxiety, depression), though debates persist about its factor structure (two-factor vs. unidimensional models). Predictive validity is robust, linking higher scores to poorer health outcomes, such as reduced immune function and chronic disease risk. Clinically and in research, the PSS-14 is used to assess stress in diverse populations (e.g.,gastrointestinal and colorectal cancer) [21] and evaluate interventions (e.g., family and peer support groups) [22]. The PSS-14 scale has been translated into Greek and has been used in research in Greece among the adult population living in urban areas by Katsarou et al. [23] and Andreou et al. [24]. Both surveys showed good reliability in terms of internal consistency (Cronbach's a) with 0.84 and 0.82 respectively. The second scale is the State-Trait Anxiety Inventory (STAI), developed by Spielberger and colleagues in 1970, and is a widely recognized psychological assessment tool designed to evaluate state anxiety (current emotional state) and trait anxiety (general predisposition to anxiety). Comprising 40 items, the STAI is structured into two subscales: State Anxiety (S-Anxiety), which measures anxiety at a specific moment (e.g., “I am tense; I am worried”), and Trait Anxiety (T-Anxiety), which assesses enduring anxiety tendencies (e.g., “I worry too much over something that really doesn’t matter”). Items are rated on a 4-point Likert scale (e.g., “Almost Never” to “Almost Always”), with positive items (e.g., “I feel calm”) reverse-scored to avoid response bias. Psychometrically, the STAI demonstrates robust reliability and validity. Internal consistency is strong, with Cronbach’s α values of approximately 0.90 for S-Anxiety, reflecting high item cohesion. Test-retest reliability varies by subscale: S-Anxiety shows moderate stability (α = 0.54). Construct validity is supported by correlations with other anxiety measures, such as the Taylor Manifest Anxiety Scale and IPAT Anxiety Scale. Clinically, the STAI distinguishes anxiety from depressive syndromes and predicts caregiver distress, underscoring its utility in diverse contexts. Scoring involves summing responses for each subscale, yielding scores ranging from 20 to 80. Higher scores indicate greater anxiety, though clinical thresholds vary by population. For example, scores above 40–45 on S-Anxiety may signal clinically significant anxiety, though these cutoffs require population-specific validation. Applications of the STAI span clinical and research domains. It is employed to diagnose anxiety disorders, monitor treatment efficacy, and assess caregiver burden. In research, it has been used to study anxiety in cancer patients, caregivers, and other vulnerable groups, highlighting its versatility. The questionnaire has been translated and adapted into Greek by Liakos & Giannitsi in1984 [25] but the validity and reliability check were later carried out by Anagnostopoulou & Kioseoglou [26] in 2002. The S-Anxiety subscales show excellent internal consistency with Cronbach's coefficients of 0.938 and 0.905 respectively. The Stressors in Breast Cancer Patients (SBCS) is an innovative tool developed by Cerezo et al. [27] specifically for individuals with breast cancer. The initial questionnaire was developed in Spanish, as the study was conducted in Spain with Spanish-speaking participants. The items were created based on focus groups and interviews with Spanish-speaking breast cancer patients and psycho-oncologists. The psychometric validation of the Stressors in Breast Cancer Scale (SBCS) was also performed using a sample of Spanish women. It considers the unique challenges faced by these patients, including concerns about physical appearance and women's interest in sex. Moreover, the SBCS is designed to be applicable throughout the entire breast cancer journey, from diagnosis to post-treatment survival (health and daily strains, interpersonal difficulties, health care strains and existential concerns such as fear about the future). More specifically the researchers identified five key dimensions of stress in breast cancer patients: Appearance and Sexuality-Related Stress (Physical changes due to treatment (e.g., mastectomy, hair loss) and concerns about femininity and sexual life. Health and Daily Life Problems (Physical symptoms and fatigue and limitations in daily activities caused by the illness. Interpersonal Relationship Issues (Impact on relationships with family, partners, and friends and challenges in managing emotional support). Healthcare System-Related Stress (Difficulties accessing treatments and medical information and frustrations with the healthcare system’s bureaucracy and delays. Worries and Fears About the Future (Fear of cancer recurrence and uncertainty about life after treatment) The psychometric properties of the original Spanish scale have been proven and then the scale has been translated into English by Cerezo et al. The SBCS has been translated, cross-culturally adapted and validated in Chinese by Hu et al. [28] and proven a good reliability and validity. Finally, to test for validity of SBCS, we correlated this instrument with two questionnaires: the Perceived Stress Scale (PSS-14) and the State-Trait Anxiety Inventory (STAI). For our study we used only the State-Anxiety (S-Anxiety) subscale measuring the emotion at the specific moment. This study aimed to translate the English version of the SBCS into Greek and evaluate its psychometric properties. The goal was to systematically assess the stress levels of breast cancer patients in Greece and provide a solid foundation for developing effective interventions, aiming to reduce stress and enhance their quality of life. The SBCS translation was conducted using a forward and backward translation method by two skilled bilingual translators. The Greek version was pre-tested on a pilot study in a small sample of five breast cancer survivors to identify any ambiguities in the scale's content and finalize the translation. Statistical analysis Psychometric properties of the SBCS The present study aimed to examine the psychometric properties of the Greek version of the Stressors in Breast Cancer Scale [27]. The SBCS was developed to identify the specific sources of stress experienced by women diagnosed with breast cancer, encompassing both medical and psychosocial aspects of the illness. Given the cultural, linguistic, and healthcare system differences that may influence stress perception and reporting, a rigorous cross-cultural validation was undertaken to ensure the scale’s conceptual and metric equivalence in the Greek context. The analysis focused on evaluating the internal structure, reliability, and construct validity of the instrument. Evidence for validity based on internal structure was obtained through exploratory and confirmatory factor analyses, while reliability was assessed using Cronbach’s α and McDonald’s ω coefficients. Additional validity evidence was gathered by examining the associations between the SBCS and related constructs, including perceived stress, and symptoms of anxiety. This study therefore sought to provide a psychometrically sound Greek version of the SBCS suitable for research and clinical applications among breast cancer survivors. Instruments Demographic Questionnaire This includes sociodemographic characteristics data (age, occupation, education level) and disease-related data (type of surgery and Hospital setting, Public or Private) Stressors in Breast Cancer Scale (SBCS). The SBCS [27] assessed stressors specifically related to the experience of breast cancer. It comprises 24 items related to five theoretical dimensions (physical appearance and sex strains, health and daily difficulties, interpersonal relationship strains, healthcare strains, and worries and concerns about the future), each rated on a 5-point Likert-type scale (1 = not at all stressful or is irrelevant to me; 5 = very stressful), with higher scores indicating greater perceived stress. One sample item is ‘Finding it hard to take care of people who depend on me (e.g., children, grandchildren, parents)’. The SBCS provides both scores for each subscale and a total score representing overall cancer-related stress, by summing the subscale scores. In the present study, the scale was translated and adapted into Greek following international guidelines for cross-cultural adaptation of psychological instruments, including forward and backward translation, expert panel review, and pilot testing for clarity and cultural relevance. The Greek version was then subjected to psychometric validation, replicating the statistical procedures of the original Spanish validation study. In the original development study, Cerezo et al. [27] reported a five-factor structure consistent with the theoretical model and excellent internal consistency, with McDonald’s ω and Cronbach’s α ranging from .83 to .89 across factors and .95 for the total score. In the current study, the Cronbach’s alpha for the total scale was α = .94, indicating high internal consistency. PSS-14. The 14-item Perceived Stress Scale [29] assesses the degree to which situations in one's life are appraised as stressful over the past month. Items are rated on a 5-point frequency scale ranging from 0 (never) to 4 (very often). The scale includes seven positively worded items that are reverse-scored and seven negatively worded items that are scored directly. Total scores range from 0 to 56, with higher scores indicating higher levels of perceived stress. The Greek version has shown adequate reliability [24]. In the current study, the Cronbach’s alpha for the total scale was α = .88, indicating high internal consistency. STAI. Each section of the assessment (State and Trait) has a possible score of 20 to 80. In general, higher scores indicate more severe anxiety. Some items on the assessment are reverse scored to account for positively worded items. For that reason, certain questions are scored in reverse There’s no universal cutoff for anxiety levels as with other tests, but State Trait Anxiety Inventory scores could be grouped as: 20–37: Low anxiety 38–44: Moderate anxiety 45–80: High anxiety Several items on the STAI were reversed coded Recommended for studying anxiety in research and clinical settings. In the current study, the Cronbach’s alpha for the total scale was α = .96, indicating high internal consistency. Data analysis All statistical analyses were conducted using IBM SPSS Statistics (Version 25; IBM Corp., 2017) and R (Version 4.3.1; R Core Team, 2023). The lavaan package [30] was used for confirmatory factor analysis (CFA) and structural equation modeling procedures. Descriptive statistics (means, standard deviations, skewness, and kurtosis) were first calculated for all 24 SBCS items to examine score distributions and assess normality. Skewness and kurtosis values within ± 2 were considered acceptable indicators of normality. To obtain validity evidence based on the internal structure, an exploratory factor analysis (EFA) was conducted using the minimum residuals extraction method with oblimin rotation. Factor retention was guided by parallel analysis and theoretical interpretability. Sampling adequacy was verified with the Kaiser–Meyer–Olkin (KMO) index and Bartlett’s test of sphericity. Because the sample size (N = 216) did not permit random division into two independent subsamples, the EFA and subsequent confirmatory factor analysis (CFA) were conducted sequentially on the same dataset. This sequential approach, while methodologically suboptimal compared to split-sample designs, has been documented as a pragmatic strategy in psychometric validation studies with modest samples where random division is not feasible [31] [32]. Readers should interpret the CFA results as an assessment of consistency between the empirical structure and the theoretical model, rather than as a fully independent cross-validation. The CFA tested a second-order, five-factor structure representing the following dimensions: physical appearance and sex strains, health and daily difficulties, interpersonal relationship strains, healthcare strains, and worries and concerns about the future. Model fit was evaluated using the chi-square statistic (χ²), comparative fit index (CFI), Tucker–Lewis index (TLI), root mean square error of approximation (RMSEA) with 90% confidence intervals, and standardized root mean square residual (SRMR). Acceptable model fit was defined as CFI and TLI ≥ .90 and RMSEA ≤ .08 [33]. Internal consistency was examined using Cronbach’s α and McDonald’s ω, with values ≥ .70 considered satisfactory [32]. Composite reliability (CR) and average variance extracted (AVE) were also calculated to assess convergent validity, with thresholds of .70 and .50, respectively [34]. Discriminant validity was examined by comparing the square roots of AVE values with the inter-factor correlations. Validity evidence based on relationships with other variables was assessed through Pearson’s correlations between SBCS scores and the Perceived Stress Scale (PSS-14) and State–Trait Anxiety Inventory (STAI). Correlation magnitudes of |.10|, |.30|, and |.50| were interpreted as small, moderate, and large, respectively [35]. Missing Data: The dataset was complete with no missing values for any of the study variables (SBCS, PSS-14, STAI, or demographic information). All 216 participants included in the analyses had complete data across all measures. Finally, descriptive statistics (means, standard deviations, skewness, and kurtosis) were computed for the five SBCS dimensions and the total score to provide an overall indicator of cancer-related stress. Results Descriptive Statistics Descriptive statistics for each item of the SBCS are presented in Table 2 . Item means ranged from 1.85 to 3.75 ( SD = 1.13–1.54). Skewness and kurtosis values were within acceptable limits (± 2), indicating no severe deviations from normality. Table 2 Mean (M), standard deviation (SD), and skewness and kurtosis for items of the SBCS (N = 216) Item M SD Skewness Kurtosis SBCS1 3.02 1.24 –0.14 –1.05 SBCS2 2.74 1.41 0.18 –1.31 SBCS3 3.05 1.39 –0.04 –1.24 SBCS4 2.82 1.43 0.17 –1.32 SBCS5 2.47 1.33 0.49 –0.93 SBCS6 2.59 1.32 0.34 –1.04 SBCS7 2.76 1.25 0.19 –0.95 SBCS8 2.57 1.33 0.29 –1.18 SBCS9 2.35 1.30 0.54 –0.91 SBCS10 1.87 1.12 1.21 0.60 SBCS11 1.92 1.17 1.17 0.44 SBCS12 2.12 1.27 0.88 –0.39 SBCS13 2.44 1.32 0.47 –1.04 SBCS14 2.26 1.25 0.70 –0.59 SBCS15 2.16 1.33 0.83 –0.63 SBCS16 2.75 1.31 0.17 –1.16 SBCS17 1.85 1.13 1.15 0.24 SBCS18 2.13 1.23 0.80 –0.48 SBCS19 2.09 1.16 0.81 –0.34 SBCS20 3.75 1.27 –0.56 –0.98 SBCS21 2.52 1.42 0.48 –1.09 SBCS22 2.36 1.38 0.62 –0.95 SBCS23 3.05 1.45 0.01 –1.39 SBCS24 3.05 1.54 –0.05 –1.50 The total SBCS demonstrated excellent internal consistency (Cronbach’s α = .94; McDonald’s ω = .95). Item–total correlations ranged from .46 to .75, indicating adequate homogeneity among items. Exploratory Factor Analysis Given that the sample size did not permit random division into two independent subsamples, the exploratory and confirmatory analyses were performed sequentially on the same dataset. This approach has been applied in previous scale validation studies with comparable samples [32]. An exploratory factor analysis (EFA) using the minimum residuals extraction method with oblimin rotation and parallel analysis supported a five-factor solution consistent with the theoretical model of the SBCS (physical appearance and sex strains, health and daily difficulties, interpersonal relationship strains, healthcare strains, and worries and concerns about the future). The results are presented in Table 3 . The Kaiser–Meyer–Olkin index was .92, and Bartlett’s test of sphericity was significant, χ²(276) = 3409.03, p < .001, confirming sampling adequacy. Table 3 Factor loadings (above 0.30) from the EFA of the SBCS ( N = 216). Items Factor 1 2 3 4 5 SBCS1 0.496 SBCS2 0.441 SBCS3 0.654 SBCS4 0.737 SBCS5 0.547 SBCS6 0.569 SBCS7 0.768 SBCS8 0.832 SBCS9 0.756 SBCS10 0.484 SBCS11 0.317 SBCS12 0.438 SBCS13 0.653 SBCS14 0.997 SBCS15 0.672 SBCS16 0.368 SBCS17 0.729 SBCS18 0.864 SBCS19 0.835 SBCS20 0.811 SBCS21 0.731 SBCS22 0.390 SBCS23 0.640 SBCS24 0.912 Note. F1 = Health and daily difficulties (SBCS5–9, 10, 12), F2 = Worries and concerns about the future (SBCS20–24), F3 = Healthcare strains (SBCS15–19), F4 = Interpersonal relationship strains (SBCS11, 13, 14), F5 = Physical appearance and sex strains (SBCS1–4) Confirmatory Factor Analysis Given the modest sample size, the exploratory factor analysis revealed minor deviations from the original structure - for example, certain items (e.g., SBCS10) showed higher loadings on different factors compared to the theoretical configuration proposed by Cerezo et al. [27]. To evaluate whether these empirical differences represented meaningful structural variations or sample-related fluctuations, two hierarchical models were tested: one based on the original Spanish five-factor structure and one reflecting the empirical loadings observed in the present data. The original structure, based on the Spanish validation by Cerezo et al. [27], provided a slightly better fit, χ²(247) = 565.18, p < .001, CFI = .89, TLI = .87, RMSEA = .08, SRMR = .07 (Table 4 ), than the revised model, χ²(247) = 644.89, p < .001, CFI = .88, TLI = .87, RMSEA = .09, SRMR = .08. The difference in model fit was minimal (ΔCFI = .007; ΔRMSEA = .009), but the original configuration offered a more parsimonious and theoretically coherent representation of the construct. Therefore, the original five-factor second-order model was retained for subsequent analyses. Table 4 Goodness-of-fit indices for the second-order factor model of the SBCS (N = 216). Model χ² Df CFI TLI RMSEA (90% CI) SRMR Total sample 565.18 247 .886 .872 .083 [.074, .092] .072 Using robust maximum likelihood estimation (MLR), the retained model showed an acceptable fit: χ²(247) = 565.18, p < .001, CFI = .89, TLI = .87, RMSEA = .08 [90% CI = .07, .09], SRMR = .07. All standardized factor loadings were significant (p < .001) and ranged from .63 to .91, supporting the hypothesized hierarchical structure. Although CFI and TLI values were marginally below conventional cutoffs, the remaining indices (RMSEA, SRMR) indicated a satisfactory model fit. The five first-order factors—representing physical appearance and sex strains, health and daily difficulties, interpersonal relationship strains, healthcare strains, and worries and concerns about the future, loaded significantly on a higher-order general stress factor (β = .72–.92). These results align with the Spanish validation study and support the factorial validity of the Greek version of the SBCS. The standardized second-order confirmatory factor model for the Greek version of the Stressors in Breast Cancer Scale (SBCS) is shown in Fig. 1 . The model includes one higher-order factor ( G = general stress) and five first-order factors representing (F1) physical appearance and sex strains, (F2) health and daily difficulties, (F3) interpersonal relationship strains, (F4) healthcare strains, and (F5) worries and concerns about the future. All paths were statistically significant ( p < .001). Although CFI and TLI values were slightly below conventional thresholds, they approached acceptable levels, particularly given the complexity of the model and sample size. Note Standardized path coefficients are displayed. G = general stress; F1–F5 = first-order factors corresponding to the five SBCS dimensions. Reliability and Convergent Validity Internal consistency was excellent across all dimensions (α = .80–.89; ω = .82–.90) and for the total scale (α = .94; ω = .95). Convergent validity was confirmed with Average Variance Extracted (AVE = .56–.68) and Composite Reliability (CR = .82–.90) values exceeding recommended thresholds (.50 and .70, respectively) [34]. Results are demonstrated in Table 5 . Table 5 Item–factor correlations, corrected item–total correlations, McDonald’s ω, Cronbach’s α, and average variance extracted (AVE) for the five factors and total score of the SBCS (N = 216). SBCS factor / items Item–factor correlation Corrected item–total correlation Cronbach’s α McDonald’s ω AVE Physical appearance and sex strains (F1) .80 .82 .56 SBCS1 .66 .55 SBCS2 .65 .56 SBCS3 .68 .46 SBCS4 .90 .66 Health and daily difficulties (F2) .89 .90 .63 SBCS5 .70 .55 SBCS6 .81 .71 SBCS7 .81 .59 SBCS8 .81 .63 SBCS9 .77 .65 Interpersonal relationship strains (F3) .85 .86 .64 SBCS10 .76 .71 SBCS11 .70 .60 SBCS12 .71 .66 SBCS13 .73 .63 SBCS14 .76 .63 Healthcare strains (F4) .88 .89 .67 SBCS15 .74 .60 SBCS16 .67 .67 SBCS17 .80 .80 SBCS18 .84 .59 SBCS19 .85 .64 Worries and concerns about the future (F5) .89 .90 .68 SBCS20 .86 .69 SBCS21 .77 .64 SBCS22 .63 .62 SBCS23 .83 .75 SBCS24 .85 .66 Total score SBCS (G) — — .94 .95 — Note. α = Cronbach’s alpha; ω = McDonald’s omega; AVE = Average Variance Extracted. Discriminant validity was also supported, as the square roots of the AVE values for each factor were greater than the inter-factor correlations. Validity Evidence Based on Relationships with Other Variables To examine convergent validity with related constructs, Pearson correlations were calculated between SBCS scores and measures of perceived stress (PSS-14) and anxiety (STAI). As expected, SBCS total scores correlated positively and strongly with both perceived stress ( r = .65, p < .001) and anxiety ( r = .67, p < .001). In the original validation by Cerezo et al. [27], measurement invariance was examined across groups defined by time since diagnosis (< 3 years vs. ≥3 years). In the present study, given the smaller total sample size (N = 216), the data were analyzed as a single group to ensure model stability and sufficient statistical power. Therefore, measurement invariance analyses were not performed at this stage. Future research with larger and more balanced samples should further examine the invariance of the SBCS across relevant clinical subgroups. Correlations between SBCS subscales and external measures are presented in Table 6 . Table 6 Correlations between SBCS factor and total scores and scores on perceived stress and anxiety (N = 216). Variables Physical appearance and sex strains Health and daily difficulties Interpersonal relationship strains Healthcare strains Worries and concerns about the future Total score SBCS Perceived stress (PSS-14) 0.48*** 0.45*** 0.56*** 0.53*** 0.62*** 0.65*** Anxiety (STAI) 0.48*** 0.46*** 0.62*** 0.50*** 0.66*** 0.67*** Note. SBCS = Stress in Breast Cancer Scale; PSS-14 = Perceived Stress Scale (14-item version); STAI = State–Trait Anxiety Inventory. These findings indicate that higher cancer-specific stress is associated with greater general stress and anxiety, providing strong evidence for convergent validity. Descriptive Statistics for SBCS Dimensions Descriptive statistics for the SBCS subscales and total score are presented in Table 7 . The worries and concerns about the future subscale showed the highest mean score, followed by health and daily difficulties. Table 7 Means, standard deviations, and skewness and kurtosis for scores on the SBCS (its five dimensions and total; N = 216) calculated as the sum of the respective items. SBCS scores Number of items M SD Skewness Kurtosis Physical appearance and sex strains 4 11.63 4.36 0.13 −1.04 Health and daily difficulties 5 12.73 5.40 0.25 −1.11 Interpersonal relationship strains 5 10.61 4.85 0.92 0.07 Healthcare strains 5 10.97 5.08 0.75 −0.43 Worries and concerns about the future 5 14.72 5.86 0.06 −1.23 Total score SBCS 24 60.66 20.84 0.33 −0.83 Note. M = Mean; SD = Standard deviation. Scores correspond to the sum of each subscale’s items. Overall, the findings support the structural coherence and internal consistency of the SBCS-GR. Discussion This study examined the psychometric properties of the Greek version of the Stressors in Breast Cancer Scale (SBCS) [27]. The SBCS was designed to identify specific sources of stress in women diagnosed with breast cancer such as medical, psychosocial, and existential dimensions of the illness. Cross-cultural validation was necessary to ensure conceptual and metric equivalence in the Greek context, given differences in culture, language, and healthcare systems that may influence how stress is both perceived and reported. The present study aimed to evaluate the psychometric properties of the SBCS in a Greek sample. The findings support a five-factor structure consistent with the original model, alongside high internal consistency and strong associations with related constructs. Importantly, the availability of a culturally adapted instrument enables more precise assessment of patient needs in Greek oncology settings, where psychosocial screening tools remain limited. Overview of Findings The Greek SBCS showed satisfactory psychometric properties across multiple validity domains. These findings align with the transactional model of stress, suggesting that breast cancer-related stress is multidimensional and influenced by both internal appraisals and contextual factors. Exploratory factor analysis supported a five-factor structure consistent with the original Spanish validation: physical appearance and sex strains, health and daily difficulties, interpersonal relationship strains, healthcare strains, and worries and concerns about the future. Confirmatory factor analysis provided additional support for a second-order hierarchical model, with fit indices (CFI = .89, TLI = .87, RMSEA = .08, SRMR = .07). Internal consistency was excellent for the total scale (α = .94, ω = .95) and individual subscales (α = .80–.89, ω = .82–.90), comparable to both the Spanish (α = .94) and Chinese (α = .938) validations. Convergent validity was demonstrated through strong correlations with perceived stress (PSS-14: r = .65) and anxiety (STAI: r = .67), showing that cancer-specific stressors measured by the SBCS relate meaningfully to general psychological distress. Discriminant validity was confirmed, as the square roots of AVE values exceeded inter-factor correlations, indicating that the five dimensions capture distinct yet related aspects of breast cancer-related stress. Comparison with Spanish and Chinese Validations The replication of the original factor structure supports the cross-cultural robustness of the SBCS and highlights its applicability beyond the populations in which it was initially developed. Our findings replicate the psychometric properties reported in both the Spanish [27] and Chinese [28] validations. All three studies yielded a five-factor second-order structure with comparable factor loadings and excellent internal consistency. Finding the same five-factor structure in Spain, China, and now Greece suggests this stress domains reflect common experiences across different cultures. However, we observed some cross-cultural variations in the factorial structure. In our Greek sample, item SBCS10 ("Being restricted in going out with friends") loaded more strongly on the health and daily difficulties factor than on the interpersonal relationship strains factor. This may reflect cultural differences in how social restrictions are understood—Greek women with breast cancer may view reduced social engagement primarily as a consequence of physical limitations rather than relational strain. The Chinese validation showed similar patterns, with items 10 and 12 reassigned to the daily difficulties factor [28]. These structural differences, yet subtle, highlight the importance of cultural adaptation in psycho-oncology research. Western cultures may emphasize interpersonal relationships as a distinct stressor domain, whereas Greek and Chinese cultures may integrate social restrictions more closely with physical and functional limitations. Despite these differences, the overall theoretical framework remained the same across all three validations, supporting the SBCS's cross-cultural applicability. Our goodness-of-fit indices (CFI = .89, TLI = .87) were somewhat lower than those reported in the Chinese validation (CFI = .93, TLI = .91) but comparable to those from other validation studies using similar sample sizes. The Spanish validation study did not report specific fit indices, making direct comparison difficult. Importantly, RMSEA (.08) and SRMR (.07) were within acceptable thresholds, and all factor loadings were statistically significant (ranging from .63 to .91, all p < .001), supporting the structural validity of the Greek SBCS. The slightly lower CFI and TLI values should be interpreted in context: our factor loadings were as strong as those reported in larger validation studies, and the hierarchical model demonstrated clear conceptual coherence. Simulation studies demonstrate that incremental fit indices (CFI, TLI) are systematically attenuated in samples smaller than 250, with RMSEA and SRMR showing greater robustness across sample sizes [36]. Accordingly, RMSEA (.08) and SRMR (.07), both within acceptable thresholds, are treated as primary indicators of model fit and our values still fall within ranges considered acceptable by contemporary structural equation modeling standards [37]. The strong factor loadings, combined with excellent internal consistency and meaningful construct validity associations, provide compelling evidence for the measure's structural integrity. Clinical Utility and Implementation From a clinical perspective, the SBCS-GR may serve as a practical screening tool for identifying specific domains of distress, allowing healthcare professionals to tailor psychosocial interventions more effectively.Systematic psychosocial screening remains unused in Greek oncology settings, despite international recommendations for routine distress screening. The Greek healthcare system has faced significant challenges in recent decades due to the economic crisis and the Pandemic, affecting cancer care delivery and limiting access to psycho-oncology services [38]. Therefore, brief, validated screening scales are essential for identifying patients who would benefit from specialist psycho-oncology care. The multidimensional structure of the SBCS-GR has direct implications for clinical decision-making. Patients who score high on the appearance and sexuality dimension (Items 1–4) are experiencing significant distress related to treatment-related physical changes and may benefit from body image counseling, psychosexual therapy, or consultation with plastic surgeons regarding reconstruction options. In contrast, women showing elevated scores on health and daily functioning difficulties (Items 5–9) are struggling primarily with symptom burden and functional limitations. For these patients, oncology teams might prioritize referrals to physiotherapy, or fatigue management programs rather than psychological counseling. The interpersonal relationship area (Items 10–14) identifies a different group of clinical needs. Women scoring high in this field are experiencing stress in their family relationships and caregiving roles and difficulties with emotional expression. These patients would benefit from couples therapy, family counseling, or communication skills training. In the same way, the healthcare system navigation dimension (Items 15–19) points stressors related to appointment scheduling, treatment coordination, information gaps and anxiety due to medical bureaucracy. Patients struggling in this area require practical support such as patient navigator services, treatment information help desk or healthcare advocacy instead of psychological support. Finally, the worries and concerns about the future dimension (Items 20–24), which presented the highest mean scores in our sample, identifies women experiencing fear of cancer recurrence and existential distress. These patients are more likely to benefit from cognitive-behavioural interventions or meaning-centered psychotherapy addressing existential concerns. What differentiates the SBCS from generic distress measures is that the SBCS identifies which particular stressors are generating that distress. In that way, clinicians are guided towards appropriate, personalized and effective referral decisions. A woman scoring high on appearance concerns but low on future worries requires fundamentally different support than one with the reverse profile, even if both might score similarly on a generic anxiety item. From a practical implementation viewpoint, the SBCS is feasible for routine clinical use. Its administration takes approximately five to seven minutes and can be completed in a waiting room using either e-form or paper formats. In healthcare contexts like the Greek public health system lacking resources, the SBCS allows allocation of limited psycho-oncology care by matching patients to the services needed. This approach represents a shift from reactive crisis intervention towards preventive and supportive care. Cultural Context and Healthcare System Considerations The Greek validation provides insight into how cultural values and healthcare system characteristics may influence the experience and reporting of cancer-related stressors. Greece is characterized by strong family structures, good social support networks, and high levels of family involvement in healthcare decision-making [39]. These cultural factors may partially explain why interpersonal relationship strains yielded lower scores compared to other dimensions. The Greek healthcare system has experienced significant challenges in recent decades, affecting cancer care delivery and patient psychological support. Economic constraints have limited access to specialized psycho-oncology services, with fewer than 20% of cancer centers providing systematic psychological assessment and support [38]. This gap makes the availability of brief, validated screening instruments particularly important for identifying women who might benefit from psychological intervention. While Greek translations exist for generic stress and anxiety measures, there is a notable absence of cancer-specific stress assessment instruments validated for the Greek population. This validation addresses a critical need for culturally appropriate, disease-specific assessment in Greek oncology settings. Clinical and Research Implications A psychometrically sound Greek version of the SBCS has significant implications for both clinical practice and research. Clinically, the SBCS can serve as a brief (5–7 minute) screening tool integrated into routine oncology care, enabling systematic identification of specific stress domains requiring intervention. Given that 40–60% of breast cancer patients experience clinically significant psychological distress yet fewer than 30% receive psychosocial support [7], systematic screening with domain-specific assessment represents a critical gap in Greek oncology care. The SBCS's five-factor structure allows oncology teams to move beyond generic distress screening toward precision-matched interventions: women scoring high on physical appearance and sexuality strains (subscale mean > 3.5 on 5-point scale) may benefit from evidence-based body image interventions or sexual rehabilitation programs integrated into survivorship care, whereas those with elevated scores on worries and concerns about the future may require cognitive-behavioral therapy targeting fear of cancer recurrence—an intervention shown to reduce fear by 40–50% in randomized trials [18]. The SBCS enables oncology teams to implement tailored, stepped-care models. Patients with low-to-moderate total SBCS scores (below sample median) may benefit from psychoeducational resources and peer support groups, while those scoring above the 75th percentile require referral to specialized psycho-oncology services. This stratification approach maximizes limited mental health resources while ensuring high-need patients receive intensive intervention. Multidisciplinary oncology teams can use SBCS subscale profiles to coordinate care: physical therapists addressing body image concerns (physical appearance subscale), social workers facilitating healthcare navigation (health system subscale), and psychologists targeting future-oriented anxiety (worries subscale). Such coordinated care models have demonstrated 30–40% reductions in psychological distress and improved treatment adherence in breast cancer populations [22]. The SBCS can inform culturally adapted psychosocial interventions. Given that worries about the future emerged as the most prominent stressor in our sample (M = 3.82, highest subscale mean), interventions targeting fear of cancer recurrence may be particularly relevant for Greek populations. International data suggest fear of recurrence affects 50–70% of breast cancer survivors and is associated with reduced quality of life, increased healthcare utilization, and poorer treatment adherence [11]. The moderate scores on interpersonal relationship strains (M = 2.45) suggest that family-centered interventions, which leverage existing strong family support networks while addressing potential areas of relational tension, may be well-suited to the Greek cultural context where family involvement in cancer care is normative. From a research perspective, the SBCS enables cross-cultural comparisons of cancer-related stressors across the Spanish [27], Chinese [28], and now Greek validations, facilitating identification of universal versus culture-specific sources of distress. Preliminary cross-cultural data suggest physical appearance concerns are universally elevated (M > 3.5 across all three validations), whereas interpersonal relationship strains show cultural variation (higher in collectivist cultures), informing culturally responsive intervention development. Longitudinal studies using the SBCS could examine trajectories of stress across the cancer continuum, from diagnosis through treatment, survivorship, and potential recurrence. Such research could identify critical time points when specific stressors peak—existing literature suggests physical appearance concerns peak during active treatment (chemotherapy-related hair loss, surgical changes), while future worries intensify at treatment completion when medical surveillance decreases [19]—informing optimal timing of psychosocial interventions. The SBCS can evaluate the efficacy of stress-reduction interventions in Greek populations. By administering the scale before and after intervention, researchers can assess changes in specific stressor domains and determine which interventions are most effective for which types of stress—for example, whether mindfulness-based interventions preferentially reduce future-oriented worry versus present-focused physical concerns. The SBCS could also serve as a mediator variable in studies examining whether reducing cancer-specific stress mediates the relationship between psychosocial interventions and health outcomes such as quality of life (demonstrated effect sizes d = 0.4–0.6 in meta-analyses), treatment adherence, immune function markers, and disease progression. Such mechanistic research could elucidate pathways through which psychosocial interventions improve cancer outcomes, strengthening the evidence base for integrating mental health care into standard oncology practice. Study Limitations Although the use of a single sample for both EFA and CFA may limit strict cross-validation, this approach has been adopted in similar psychometric studies with moderate sample sizes. The primary limitation is sample size (N = 216). While adequate for EFA and CFA according to recommended subject-to-item ratios, the sample size precluded certain advanced psychometric analyses. Specifically, measurement invariance across clinically relevant subgroups (e.g., time since diagnosis, treatment type, disease stage) could not be examined due to insufficient subsample sizes. The Chinese validation [28], with a larger sample (N = 878), demonstrated measurement invariance across time since diagnosis (< 3 years vs. ≥3 years), suggesting that the SBCS structure remains stable across disease trajectory. Future Greek studies with larger samples should prioritize this analysis to ensure that SBCS scores are comparable across different clinical subpopulations. We did not assess test-retest reliability in this study. This decision reflects the nature of what the SBCS measures. The scale assesses stressors—external demands and challenges that women with breast cancer face—rather than stable personality traits. These stressors naturally change as patients move through their cancer journey. Treatment side effects come and go, relationships shift, fears about the future fluctuate, and healthcare interactions vary. Asking patients to complete the same questionnaire twice within a short period would not tell us whether the scale is reliable. Instead, it would likely show us that their actual stressors had changed, which is exactly what we would expect. This is different from measuring something like anxiety proneness or coping style, which tend to be more stable over time. Both the original Spanish validation and the Chinese validation made the same decision not to include test-retest assessment, suggesting this is a recognized consideration for instruments that measure changing experiences rather than stable characteristics. This approach is consistent with recommendations for instruments measuring dynamic, state-like experiences rather than stable traits, for which internal consistency and construct validity constitute more meaningful psychometric evidence than temporal stability [31]. What matters more for a scale like this is whether it consistently measures the construct at a single point in time (internal consistency) and whether it relates to other relevant measures in expected ways (construct validity). Our analyses showed strong evidence for both of these properties. Convenience sampling and recruitment primarily through cancer support associations and a private hospital may have introduced selection bias. Participants were predominantly urban, well-educated (70% with university degrees), and employed (68%), which may limit generalizability to rural, lower-educated, or economically disadvantaged populations. The majority of participants (66%) received care in private hospitals, which may reflect higher socioeconomic status and differential healthcare experiences compared to those relying exclusively on public healthcare. Future research should prioritize recruitment from diverse geographical regions and healthcare settings. Moreover, time since diagnosis was not systematically collected as a demographic variable, limiting our ability to examine potential variations in stressor patterns across different stages of the disease trajectory. The study also has notable strengths that support confidence in the findings. Our sample of 216 women exceeds the recommended minimum of 200 participants for confirmatory factor analysis and provides adequate statistical power for the primary psychometric analyses conducted. We assessed multiple forms of validity (convergent, discriminant) rather than relying solely on factor structure, and followed established international guidelines [17] for translation and cross-cultural adaptation. The rigorous forward-backward translation process, combined with cognitive interviews and pilot testing, ensured conceptual equivalence rather than mere literal translation. Perhaps most importantly, our findings closely replicate results from both the Spanish original and Chinese validation studies, despite substantial differences in sample sizes (N = 455, N = 879, N = 216), recruitment settings, and cultural contexts. This pattern of consistent structural replication across three linguistically and culturally distinct populations—Southern European, East Asian, and Southeastern European—provides robust evidence that the SBCS captures fundamental dimensions of breast cancer-related stress that generalize across diverse contexts. The convergence of findings strengthens confidence that observed relationships reflect true psychometric properties rather than sample-specific artifacts. Future Directions Several critical research directions emerge from this validation, each addressing specific methodological limitations while advancing understanding of cancer-related stress in Greek populations. Future studies should examine test–retest reliability and replicate the findings in more diverse and clinical samples Comprehensive validation requires independent replication with larger, more diverse samples recruited through probability-based methods. Our convenience sample (N = 216), while adequate for preliminary factor structure examination, limits generalizability and statistical power for advanced analyses. Future studies should employ stratified random sampling from cancer registries to ensure representation across disease stages (early-stage vs. metastatic), treatment modalities (surgery-only vs. combined treatments), age cohorts, geographic regions (urban Athens vs. rural areas), and socioeconomic strata. Sample sizes of 400–500 would enable measurement invariance analyses to ensure that SBCS scores are comparable across these clinically relevant subgroups—a prerequisite for meaningful group comparisons, identification of high-risk populations, and longitudinal research examining stress trajectories across the cancer continuum. Establishing test-retest reliability represents an urgent priority absent from this study. Without temporal stability data, we cannot distinguish true change in stressor exposure from measurement error, limiting the SBCS's utility for monitoring individual patients over time or evaluating intervention efficacy. A 2- to 4-week test-retest interval is recommended, as this timeframe is sufficiently long to reduce memory effects but short enough to minimize genuine change in stressor exposure. Intraclass correlation coefficients ≥ .70 would indicate acceptable stability for clinical use. Future research should also examine responsiveness to change following psychosocial interventions, establishing minimal clinically important differences for total and subscale scores to guide intervention evaluation and clinical decision-making. Addressing the same-sample exploratory and confirmatory factor analysis conducted in this study requires independent cross-validation. Ideally, future research should employ a three-sample design: an initial exploratory sample (n ~ 300) for factor structure examination, an independent confirmatory sample (n ~ 300) for model testing, and a third validation sample (n ~ 300) for invariance testing and criterion validity assessment. This design overcomes the statistical dependencies and potential overfitting inherent in conducting EFA and CFA on identical data, providing more robust evidence of structural validity. Multi-group CFA across samples would test factorial invariance, establishing whether the five-factor structure replicates consistently or requires culture-specific modifications. Beyond psychometric refinement, mitigating self-report bias requires multi-method validation. Exclusive reliance on self-report measures in this study introduces shared method variance, potentially inflating correlations with other self-report instruments (e.g., PSS, STAI) and raising concerns about social desirability bias, particularly for sensitive items addressing interpersonal relationship strains or healthcare system frustrations. Future research should incorporate objective indicators (medical records data on treatment adherence, healthcare utilization patterns), clinician-rated assessments (oncologist or nurse ratings of patient distress), behavioral measures (cortisol levels as physiological stress markers, actigraphy-measured sleep disruption), and significant-other reports (partner or family member assessments of patient stress) to establish convergent validity across methods. Discrepancies between self-report and objective measures could reveal important insights into awareness, denial, or communication patterns requiring clinical attention. A complementary qualitative approach could deepen understanding of Greek women's lived experiences of cancer-related stressors. Focus groups or in-depth phenomenological interviews could uncover culturally specific stressors not fully captured by the SBCS's Spanish-origin item pool—for example, concerns about burdens on extended family networks prevalent in collectivist Greek culture, navigation challenges within Greece's complex public-private healthcare system, economic stressors related to treatment costs and work disruption particularly salient during economic instability, or spiritual and religious dimensions of cancer-related distress. Such qualitative data could inform development of culture-specific supplementary items, enhancing the SBCS's cultural validity and clinical utility in Greek contexts. Equally important is examining potential moderators and mediators of the relationship between SBCS scores and psychological outcomes. Social support quality and quantity, active versus avoidant coping strategies, personality traits (resilience, neuroticism, optimism), healthcare system factors (continuity of care, patient-provider communication quality, access to psychosocial services), and socioeconomic resources may buffer or exacerbate the impact of cancer-specific stressors on anxiety, depression, and quality of life. Identifying these moderators through moderated regression or structural equation modeling would enable development of targeted interventions—for example, social support interventions for isolated patients with high interpersonal relationship strain, or healthcare navigation assistance for those scoring high on health system stress. Mediation analyses could test whether reducing specific stressor domains (e.g., future worries via fear of recurrence interventions) mediates improvements in broader mental health outcomes, elucidating mechanisms of psychosocial intervention efficacy. Systematic cross-cultural comparisons using the SBCS across countries where validation has been completed (Spain, China, Greece) or is underway could illuminate universal versus culture-specific aspects of cancer-related stress. Multi-national datasets would enable tests of measurement invariance across cultures, determining whether the five-factor structure holds universally or requires culture-specific modifications. Cross-cultural mean comparisons (with appropriate invariance testing) could reveal whether certain stressor domains (e.g., physical appearance concerns, healthcare system navigation) are universally elevated or show cultural variation, informing development of globally applicable versus culturally tailored psychosocial interventions. Such research could also examine whether relationships between SBCS scores and outcomes (quality of life, treatment adherence, survival) are culturally invariant or moderated by cultural values, healthcare system characteristics, or social support norms. Addressing these methodological limitations and pursuing these research directions would transform the SBCS from a promising instrument into a comprehensively validated, culturally sensitive, clinically actionable tool for assessment and intervention in Greek breast cancer care. Conclusion In conclusion, the SBCS-GR demonstrates satisfactory psychometric properties and offers a promising tool for assessing multidimensional stress in breast cancer patients. Its use may enhance both clinical screening and research in psycho-oncology in Greek populations. This validation has important implications for clinical use in Greece. Multidisciplinary oncology teams now rely only on generic distress measures that identify whether a patient is stressed but provide little guidance about the distress nature. The SBCS-GR changes this by indicating specific stressors such as appearance concerns, physical symptoms, relationship difficulties, healthcare navigation problems, or fear of recurrence. This information matters because different stressors require different interventions. A woman distressed primarily by body image changes due to a mastectomy needs different support than one whose main concern is finding the pathway to the healthcare system or facing fear of disease recurrence. This specificity is considered particularly valuable in the Greek setting, where psycho-oncology infrastructure remains limited. The SBCS-GR helps clinicians make referral decisions, matching patients to the most appropriate interventions to their needs. This validation also supports the basis for evidence-based survivorship care in Greece. Researchers now have a psychometrically and culturally appropriate tool for studying stress in Greek breast cancer patients but also for evaluating interventions designed to reduce specific types of breast cancer-related distress. The Greek version of the SBCS demonstrates robust psychometric properties and successfully replicates findings from Spanish and Chinese validations, establishing it as a reliable and valid measure of cancer-specific stress. The scale shows excellent internal consistency (α = .94), theoretically coherent factor structure, and meaningful associations with established measures of psychological distress. Despite a smaller sample than the original validations, our results closely mirror those from other cultural contexts, with remarkably similar factor loadings and internal consistency estimates. This cross-cultural convergence suggests the SBCS captures universal dimensions of the breast cancer experience while remaining sensitive to individual variation in stress experiences. The instrument fills a critical gap in Greek psycho-oncology assessment by providing the first validated, cancer-specific stress measure for this population. It offers clinicians and researchers a brief (5–7 minute administration time), psychometrically sound tool for systematically identifying specific stressors that breast cancer patients experience across the disease continuum—from diagnosis through treatment and into survivorship. This validation represents an important contribution to evidence-based assessment in Greek oncology settings and enables future research examining how cancer-specific stress relates to health outcomes, quality of life, and psychological adjustment in Greek breast cancer populations. Moreover, the availability of validated SBCS versions in Spanish, Chinese, and now Greek creates opportunities for meaningful cross-cultural research that can illuminate both universal and culture-specific aspects of cancer-related stress, ultimately informing more culturally responsive supportive care interventions. Declarations Ethics approval and consent to participate This study was approved by the Research Ethics Committee of Panteion University (Reg. Num. 52/10-03-2025). Consent for publication: Not applicable. Funding: This research received no grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution K.C. wrote the main manuscript text, G. R: prepared the figures and E.K supervised. All authors reviewed the manuscript. Acknowledgement We thank Alma Zois (Panhellenic Association of Women with Breast Cancer) and the 2nd Breast Clinic of IASO Hospital for facilitating participant recruitment and all the women who participated in this study. Availability of data and materials: The datasets generated and analyzed during the current study are not publicly available due to ethical restrictions and participant confidentiality but are available from the corresponding author upon request and with appropriate ethical approval. Competing interests: The authors declare that they have no competing interests. References Torre LA, Siegel RL, Ward EM, Jemal A. Global cancer incidence and mortality rates and trends--An update. Cancer Epidemiol Biomarkers Prev. 2016;25(1):16-27. doi:10.1158/1055-9965.EPI-15-0578 Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229-263. doi:10.3322/caac.21834 Noman S, Shahar HK, Abdul Rahman H, Ismail S, Abdulwahid Al-Jaberi M, Azzani M. The effectiveness of educational interventions on breast cancer knowledge, awareness, and screening behavior: Systematic review and meta-analysis. Int J Environ Res Public Health. 2021;18(1):263. doi:10.3390/ijerph18010263 Selye H. The stress of life. Revised edition. New York: McGraw-Hill; 1978. Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer Publishing Company; 1984. Lu S, Wei F, Li G. The evolution of the concept of stress and the framework of the stress system. Cell Stress. 2021;5(6):76-85. doi:10.15698/cst2021.06.250 Tsaras K, Papathanasiou IV, Mitsi D, Veneti A, Kelesi M, Zyga S, Fradelos EC. Assessment of depression and anxiety in breast cancer patients: Prevalence and associated factors. Asian Pac J Cancer Prev. 2018;19(6):1661-1669. doi:10.22034/APJCP.2018.19.6.1661 Mystakidou K, Tsilika E, Parpa E, Katsouda E, Vlahos L. Psychological distress of patients with advanced cancer: Influence and contribution of pain severity and pain interference. Cancer Nurs. 2004;27(3):197-205. doi:10.1097/00002820-200405000-00004 Liu L, Wu Y, Cong W, Hu M, Li X, Zhou C. Experience of women with breast cancer undergoing chemotherapy: A systematic review of qualitative research. Qual Life Res. 2021;30(5):1249-1265. doi:10.1007/s11136-020-02754-5 Boing L, Pereira GS, Araújo CDCR, Sperandio FF, Loch MDSG, Bergmann A, Borgatto AF, Guimarães ACA. Factors associated with depression symptoms in women after breast cancer. Rev Saude Publica. 2019;53:30. doi:10.11606/S1518-8787.2019053000786 Parikh D, De Ieso P, Garvey G, Thachil T, Ramamoorthi R, Penniment M, Jayaraj R. Post-traumatic stress disorder and post-traumatic growth in breast cancer patients--A systematic review. Asian Pac J Cancer Prev. 2015;16(2):641-646. doi:10.7314/apjcp.2015.16.2.641 Cooper K, Campbell F, Harnan S, Sutton A. Association between stress, depression or anxiety and cancer: Rapid review of reviews. Compr Psychoneuroendocrinol. 2023;16:100215. doi:10.1016/j.cpnec.2023.100215 Kalaitzi C, Papadopoulos VP, Michas K, Vlasis K, Skandalakis P, Filippou D. Combined brief psychosexual intervention after mastectomy: Effects on sexuality, body image, and psychological well-being. J Surg Oncol. 2007;96(3):235-240. doi:10.1002/jso.20835 Romito F, Lagattolla F, Costanzo C, Giotta F, Mattioli V. Music therapy and emotional expression during chemotherapy: How do breast cancer patients feel? Eur J Integr Med. 2013;5(5):438-442. doi:10.1016/j.eujim.2013.04.001 Zakowski SG, Ramati A, Morton C, Johnson P, Flanigan R. Written emotional disclosure buffers the effects of social constraints on distress among cancer patients. Health Psychol. 2004;23(6):555-563. doi:10.1037/0278-6133.23.6.555 Bjelic-Radisic V, Dorfer M, Tamussino K, Greimel E. Patients' view of routine follow-up after breast cancer treatment. Wien Klin Wochenschr. 2017;129(21-22):810-815. doi:10.1007/s00508-017-1278-1 Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25(24):3186-3191. doi:10.1097/00007632-200012150-00014 Mehnert A, Berg P, Henrich G, Herschbach P. Fear of cancer progression and cancer-related intrusive cognitions in breast cancer survivors. Psychooncology. 2009;18(12):1273-1280. doi:10.1002/pon.1481 Lee TY, Hsing SC, Li CC. An improved stress-scale specifically designed to measure stress of women with newly diagnosed breast cancer. Int J Environ Res Public Health. 2021;18(5):2346. doi:10.3390/ijerph18052346 Charalampopoulou M, Syrigos K, Filopoulos E, Megalooikonomou V, Vlachakis D, Chrousos G, Darviri C. Reliability and validity of the Newly Diagnosed Breast Cancer Stress Scale in the Greek population. J Mol Biochem. 2020;9:5-12. Miceli J, Geller D, Tsung A, Hecht CL, Wang Y, Pathak R, Cheng H, Marsh W, Antoni M, Penedo F, Burke L, Ell K, Shen S, Steel J. Illness perceptions and perceived stress in patients with advanced gastrointestinal cancer. Psychooncology. 2019;28(7):1513-1519. doi:10.1002/pon.5108 Shalchi Oghli S, Sadeghi R, Omranipour R, Rahimi Foroushani A, Ashoorkhani M, Tedadi Y. Comparison of the effect of mindfulness-based stress reduction therapy and usual care on quality of life in women with breast cancer. Med J Islam Repub Iran. 2024;38:16. doi:10.47176/mjiri.38.16 Katsarou A, Panagiotakos D, Zafeiropoulou A, Vryonis M, Skoularigis I, Tryposkiadis F, Papageorgiou C. Validation of a Greek version of PSS-14: A global measure of perceived stress. Cent Eur J Public Health. 2012;20(2):104-109. doi:10.21101/cejph.a3698 Andreou E, Alexopoulos EC, Lionis C, Varvogli L, Gnardellis C, Chrousos GP, Darviri C. Perceived Stress Scale: Reliability and validity study in Greece. Int J Environ Res Public Health. 2011;8(8):3287-3298. doi:10.3390/ijerph8083287 Liakos A, Giannitsi S. The reliability and validity of Spielberger's modified Greek anxiety scale. Encephalos. 1984;21:71-76. Anagnostopoulou T, Kioseoglou G. Spielberger's state-trait anger expression inventory. In: Stalikas A, Triliva S, Roussi P, editors. Psychometric tools in Greece. Greek Letters; 2002. p. 285-286. Cerezo MV, Soria-Reyes LM, Pajares B, Gómez-Millán J, Blanca MJ. Development and psychometric properties of the Stressors in Breast Cancer Scale. Front Psychol. 2023;14:1102169. doi:10.3389/fpsyg.2023.1102169 Hu W, Bao J, Yang X, Chen L, Zhu L, Wang Y, Teng Y, Sun Q. Psychometric evaluation of the Chinese version of the Stressors in Breast Cancer Scale: A translation and validation study. BMC Public Health. 2024;24:425. doi:10.1186/s12889-024-18000-3 Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396. doi:10.2307/2136404 Rosseel Y. lavaan: An R package for structural equation modeling. J Stat Softw. 2012;48(2):1-36. doi:10.18637/jss.v048.i02 Worthington RL, Whittaker TA. Scale development research: A content analysis and recommendations for best practices. Couns Psychol. 2006;34(6):806-838. doi:10.1177/0011000006288127 Viladrich C, Angulo-Brunet A, Doval E. A journey around alpha and omega to estimate internal consistency reliability. An Psicol. 2017;33(3):755-782. doi:10.6018/analesps.33.3.268401 Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6(1):1-55. doi:10.1080/10705519909540118 Fornell C, Larcker DF. Evaluating structural equation models with unobservable variables and measurement error. J Mark Res. 1981;18(1):39-50. doi:10.2307/3151312 Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988. Kenny DA, McCoach DB. Effect of the number of variables on measures of fit in structural equation modeling. Struct Equ Modeling. 2003;10(3):333-351. doi:10.1207/S15328007SEM1003_1 Marsh HW, Hau KT, Wen Z. In search of golden rules: Comment on hypothesis-testing approaches to setting cutoff values for fit indexes and dangers in overgeneralizing Hu and Bentler's (1999) findings. Struct Equ Modeling. 2004;11(3):320-341. doi:10.1207/s15328007sem1103_2 European Observatory on Health Systems and Policies. Health systems in transition: Greece health system review. World Health Organization Regional Office for Europe; 2017. Vol. 19, No. 5. Mystakidou K, Parpa E, Tsilika E, Galanos A, Vlahos L. Cancer information disclosure in different cultural contexts. Support Care Cancer. 2007;15(3):235-240. doi:10.1007/s00520-006-0115-x Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 10 May, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers invited by journal 27 Apr, 2026 Editor invited by journal 18 Apr, 2026 Editor assigned by journal 16 Apr, 2026 Submission checks completed at journal 16 Apr, 2026 First submitted to journal 15 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9429181","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634714114,"identity":"0f4c2bdc-22ae-4136-8963-3d3339cd8171","order_by":0,"name":"Katerina Chotzoglou","email":"data:image/png;base64,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","orcid":"","institution":"Panteion University of Social and Political Sciences","correspondingAuthor":true,"prefix":"","firstName":"Katerina","middleName":"","lastName":"Chotzoglou","suffix":""},{"id":634714120,"identity":"b00da7fc-378d-4722-8ec2-8103cd254993","order_by":1,"name":"Georgia Raftopoulou","email":"","orcid":"","institution":"Panteion University of Social and Political Sciences","correspondingAuthor":false,"prefix":"","firstName":"Georgia","middleName":"","lastName":"Raftopoulou","suffix":""},{"id":634714124,"identity":"640ffe85-0bec-444a-85da-71b40faa828c","order_by":2,"name":"Eirini Karakasidou","email":"","orcid":"","institution":"Panteion University of Social and Political Sciences","correspondingAuthor":false,"prefix":"","firstName":"Eirini","middleName":"","lastName":"Karakasidou","suffix":""}],"badges":[],"createdAt":"2026-04-15 15:47:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9429181/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9429181/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108940032,"identity":"db720707-aaf9-477f-a177-951fbfec5aa3","added_by":"auto","created_at":"2026-05-11 05:11:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":100547,"visible":true,"origin":"","legend":"\u003cp\u003eSecond-order confirmatory factor model of the Stressors in Breast Cancer Scale (SBCS) for the Greek sample (N = 216).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote. \u003c/strong\u003eStandardized path coefficients are displayed. G = general stress; F1–F5 = first-order factors corresponding to the five SBCS dimensions.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9429181/v1/d7519ed567defb74a2c07914.png"},{"id":108940363,"identity":"2d567486-bf0e-4daa-ac52-5ef557618d06","added_by":"auto","created_at":"2026-05-11 05:12:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":720569,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9429181/v1/7170cfc3-e80c-4567-8116-64e3d36b001e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychometric validation of the Stressors in Breast Cancer Scale in Greece: Evidence for a five- factor structure","fulltext":[{"header":"Background","content":"\u003cp\u003eBreast cancer is the most diagnosed cancer among women worldwide, according to data from the International Agency for Research on Cancer (IARC) and the World Health Organization. By 2035, an estimated 2.94\u0026nbsp;million women worldwide will be affected by breast cancer [1]. In developed countries, one in eight women will develop breast cancer in her lifetime [2]. In Greece, 8,987 women were diagnosed in 2022, with incidence rates comparable to other European countries, though ongoing efforts in early detection and treatment remain crucial to manage and reduce mortality rates.\u003c/p\u003e \u003cp\u003eBreast cancer predominantly affects older women, with the majority of patients over 50 years of age at diagnosis, although approximately one in five cases are diagnosed before age 50. Breast cancer in men is rare, accounting for about 1% of cases. Incidence rates vary considerably between geographical regions, with the highest rates in Western Europe and the United States, and the lowest in Africa and Asia. This variation reflects differing distributions of breast cancer risk factors across regions [1]. Intensifying public awareness programs represents a critical global health priority. Public health education that improves women's awareness of breast cancer signs and symptoms, and helps families understand the importance of early detection and treatment, can encourage medical consultation when breast cancer is first suspected and before any cancer progresses to advanced stages [3].\u003c/p\u003e \u003cp\u003eStress is a multifaceted concept encompassing physical, mental, and emotional elements that cause bodily or psychological tension. More specifically, stress can be defined as \"the nonspecific response of the body to any demand for change, initiating a range of physiological and psychological responses\" [4]. Stress is not purely negative, as stressful situations also provide opportunities for growth and personal development [5]. Early conceptualizations of stress focused largely on bodily disruptions to homeostasis, such as temperature changes or physical injury. Contemporary stress theories concentrate on psychological and social determinants, identifying situation appraisal and perceived availability of coping resources as central factors. Stress can be classified by its intensity, temporal pattern (acute, recurrent, or chronic), and the degree of control over the stressor [6].\u003c/p\u003e \u003cp\u003eThe diagnosis and treatment of breast cancer are extremely taxing both physically and emotionally, with treatment intensity varying by disease type and stage. Women often experience high levels of anxiety [7], diminished quality of life [8,9], elevated rates of depression [10], and post-traumatic stress [11,12]. Body image and self-esteem concerns are particularly pronounced when treatment involves mastectomy or chemotherapies that affect physical appearance [13]. Patients experience the disease as threatening, confronting anger, despair, and guilt\u0026mdash;emotions that can be difficult to recognize, process, and express [14,15]. Moreover, follow-up appointments necessary for disease monitoring or recurrence detection generate significant anxiety, with distress peaking approximately two days before appointments, particularly regarding the possibility of recurrence [16].\u003c/p\u003e \u003cp\u003eDespite increasing recognition of the psychological burden associated with breast cancer, culturally adapted instruments that capture disease-specific stressors remain limited, particularly in Southern European populations. To our knowledge, no validated instrument currently exists in Greek to assess the multidimensional stress experience of breast cancer patients. This gap limits both clinical screening and research on targeted psychosocial interventions.\u003c/p\u003e \u003cp\u003eThe present study aims to address this gap by providing a culturally adapted and psychometrically validated version of the SBCS for use in Greek clinical and research settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eThis study has been authorized by the original authors to translate the English version of SBCS in Greek language and test its reliability and validity. The research protocol was submitted for approval to the Scientific Council of both the Panhellenic Association of Women with Breast Cancer \u0026ldquo;Alma Zois\u0026rdquo; and IASO Hospital 2nd Breast Clinic. Additionally, a Confidentiality form had been signed between the researcher and IASO 2nd Breast Clinic Manager in order to get access to patients\u0026rsquo; data list and forward them the link. The sample has been selected from March, 2025 to May, 2025 using Google forms through an online interface. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The link with the set of three questionnaires (SBCS, PSS-14 and STAI) as well as social, demographic and disease related variables included age, education (primary school/secondary school/high school/higher education), employment (employed/retired/unemployed), information regarding the type of surgery (Lumpectomy/Mastectomy/Bilateral mastectomy/Breast reconstruction) and Hospital (Public/Private) had been posted on the researcher's social media, the Panhellenic Association of women with Breast Cancer \u0026ldquo;Alma Zois\u0026rdquo; website. The researcher emailed women diagnosed with breast cancer, inviting them to participate in the study. The email contained a link to a secure online survey with questionnaires, along with details about the study\u0026rsquo;s objectives and procedures. It was emphasized that participation was completely voluntary and that responses would remain anonymous. To ensure completeness, the survey could only be submitted once all questions were answered, preventing any missing data.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of the Sample (N\u0026thinsp;=\u0026thinsp;216).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge Groups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83 (38.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e120 (55.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71\u0026ndash;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (21.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92 (42.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMSc/PhD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e146 (67.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (11.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (20.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of Surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBilateral mastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreast reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLumpectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e105 (48.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73 (33.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital Setting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e143 (66.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73 (33.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote.\u003c/em\u003e Percentages are based on valid responses.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003e The Ethics Committee of Panteion University of Social and Political Sciences approved this study (Reg. Num. 52/10-03-2025), and we conducted it in accordance with the Declaration of Helsinki. We recruited participants through convenience sampling between March and May 2025. Working with staff from Alma Zois (the Panhellenic Association of Women with Breast Cancer) and the 2nd Breast Clinic of IASO Hospital in Athens, researchers identified women who met eligibility criteria and provided them with study information. Women who wanted to participate received an email explaining the study purpose (developing a validated Greek version of a breast cancer stress scale), the voluntary nature of their participation, how we would maintain confidentiality, and the estimated time needed (about 20 minutes). The email included a secure link to the online survey on Google Forms.\u003c/p\u003e \u003cp\u003e Before accessing the questionnaires, women provided electronic informed consent. The survey asked about demographics, then clinical characteristics (cancer stage, type of surgery, hospital setting), and included three psychological measures: the SBCS, PSS-14, and STAI (described in the Instruments section below). We configured the survey platform to require responses to all items before submission, which eliminated missing data. All responses were collected anonymously.\u003c/p\u003e\n\u003ch3\u003eTranslation and Cultural Adaptation\u003c/h3\u003e\n\u003cp\u003e We developed the Greek version of the SBCS following international guidelines for cross-cultural adaptation of psychological instruments [17]. The adaptation involved several steps: Forward translation: Two independent bilingual translators, both clinical psychologists who were native Greek speakers fluent in both Spanish and English, translated the 24 items from both the Spanish and English versions to Greek. Both translators had expertise in psycho-oncology terminology and were working in oncology clinics. They translated independently to ensure diverse linguistic expression. Synthesis: Our research team compared the two forward translations and created a Greek version. We resolved discrepancies through discussion and reached consensus on item wording. Back-translation: Two bilingual translators conducted independent back-translations. The first translator, a native Spanish speaker fluent in Greek, translated the Greek version back to Spanish. The second translator, a native English speaker fluent in Greek, translated the Greek version back to English. Neither translator had seen the original Spanish or English scales. We compared both back-translations with the original versions to verify semantic and conceptual equivalence. Expert committee review: We convened an expert committee of two clinical psychologists and two breast cancer survivors to review all translations alongside the original Spanish and English scales. The committee evaluated whether each item was semantically equivalent, culturally appropriate, and comprehensible for Greek breast cancer patients. They recommended minor modifications to improve clarity and cultural relevance while preserving the original meaning and structure. Pilot testing: We administered the Greek version to five breast cancer patients and asked for their feedback on item clarity, comprehensibility, and cultural appropriateness. Based on their input, we made final minor adjustments to enhance readability. Importantly, no items required substantial modification, suggesting good cross-cultural transferability of the stress constructs measured by the SBCS. The final Greek version maintained the original 24-item structure and 5-point Likert response format, demonstrating strong alignment with both the Spanish and English versions while being culturally and linguistically appropriate for Greek women with breast cancer.\u003c/p\u003e\n\u003ch3\u003eInstruments Used\u003c/h3\u003e\n\u003cp\u003eFor the assessment of stress among breast cancer patients, proper instruments should be implemented and should be tested for validity and reliability in the specific population. Such instruments are the Perceived Stress Scale (PSS-14) and the State-Trait Anxiety Inventory (STAI) that have shown high psychometric properties in the general population. However, they cover general distress perceptions and their items do not focus on breast cancer patients.\u003c/p\u003e \u003cp\u003eThere are several other instruments to assess stress among cancer patients such as the Questionnaire on Stress in Cancer Patients (QSC-R23), the Fear of Progression Questionnaire Short Form (FoP-Q-SF) [18], the Newly Diagnosed Breast Cancer Symptoms Stress Scale (NDBCSS) [19], a tool that has been examined for its validity and the reliability in the Greek population [20].\u003c/p\u003e \u003cp\u003eFor the current study, we used two of the most popular scales in Greece in order to standardize the Stressors in Breast Cancer Scale in a Greek sample.\u003c/p\u003e \u003cp\u003eThe first scale is the Perceived Stress Scale (PSS-14), developed by Sheldon Cohen and colleagues in 1983, which is a widely used psychological instrument designed to measure the degree to which individuals perceive their lives as stressful. Based on Lazarus\u0026rsquo;s transactional model of stress, the PSS-14 evaluates how unpredictable, uncontrollable, and overloaded respondents feel their lives are, emphasizing subjective appraisals of stressors rather than objective events.\u003c/p\u003e \u003cp\u003eThe original PSS-14 comprises 14 items assessing stress over the past month, with responses scored on a 5-point Likert scale (0\u0026thinsp;=\u0026thinsp;never to 4\u0026thinsp;=\u0026thinsp;very often) 7 of the questions are positive (questions 4,5,6,7,9,10,13) and are rated from 4 to 0, while the remaining 7 (1,2,3,8,11,12,14) are negative and range from 0 to 4. The total score is obtained by calculating the sum of the responses given and ranges from 0 to 56 with higher scores indicating higher levels of stress. Psychometrically, the PSS-14 demonstrates strong internal consistency, with Cronbach\u0026rsquo;s α values of 0.82\u0026ndash;0.85 for the full scale. Subscale reliabilities are slightly lower: 0.81\u0026ndash;0.85 for negativity and 0.72\u0026ndash;0.83 for positivity. Test-retest reliability is moderate for state-like stress (e.g., α\u0026thinsp;\u0026asymp;\u0026thinsp;0.54). Construct validity is supported by correlations with biological markers (e.g., cortisol levels) and psychological outcomes (e.g., anxiety, depression), though debates persist about its factor structure (two-factor vs. unidimensional models). Predictive validity is robust, linking higher scores to poorer health outcomes, such as reduced immune function and chronic disease risk.\u003c/p\u003e \u003cp\u003eClinically and in research, the PSS-14 is used to assess stress in diverse populations (e.g.,gastrointestinal and colorectal cancer) [21] and evaluate interventions (e.g., family and peer support groups) [22].\u003c/p\u003e \u003cp\u003eThe PSS-14 scale has been translated into Greek and has been used in research in Greece among the adult population living in urban areas by Katsarou et al. [23] and Andreou et al. [24]. Both surveys showed good reliability in terms of internal consistency (Cronbach's a) with 0.84 and 0.82 respectively.\u003c/p\u003e \u003cp\u003eThe second scale is the State-Trait Anxiety Inventory (STAI), developed by Spielberger and colleagues in 1970, and is a widely recognized psychological assessment tool designed to evaluate state anxiety (current emotional state) and trait anxiety (general predisposition to anxiety). Comprising 40 items, the STAI is structured into two subscales: State Anxiety (S-Anxiety), which measures anxiety at a specific moment (e.g., \u0026ldquo;I am tense; I am worried\u0026rdquo;), and Trait Anxiety (T-Anxiety), which assesses enduring anxiety tendencies (e.g., \u0026ldquo;I worry too much over something that really doesn\u0026rsquo;t matter\u0026rdquo;). Items are rated on a 4-point Likert scale (e.g., \u0026ldquo;Almost Never\u0026rdquo; to \u0026ldquo;Almost Always\u0026rdquo;), with positive items (e.g., \u0026ldquo;I feel calm\u0026rdquo;) reverse-scored to avoid response bias.\u003c/p\u003e \u003cp\u003ePsychometrically, the STAI demonstrates robust reliability and validity. Internal consistency is strong, with Cronbach\u0026rsquo;s α values of approximately 0.90 for S-Anxiety, reflecting high item cohesion. Test-retest reliability varies by subscale: S-Anxiety shows moderate stability (α\u0026thinsp;=\u0026thinsp;0.54). Construct validity is supported by correlations with other anxiety measures, such as the Taylor Manifest Anxiety Scale and IPAT Anxiety Scale. Clinically, the STAI distinguishes anxiety from depressive syndromes and predicts caregiver distress, underscoring its utility in diverse contexts.\u003c/p\u003e \u003cp\u003eScoring involves summing responses for each subscale, yielding scores ranging from 20 to 80. Higher scores indicate greater anxiety, though clinical thresholds vary by population. For example, scores above 40\u0026ndash;45 on S-Anxiety may signal clinically significant anxiety, though these cutoffs require population-specific validation.\u003c/p\u003e \u003cp\u003eApplications of the STAI span clinical and research domains. It is employed to diagnose anxiety disorders, monitor treatment efficacy, and assess caregiver burden. In research, it has been used to study anxiety in cancer patients, caregivers, and other vulnerable groups, highlighting its versatility.\u003c/p\u003e \u003cp\u003eThe questionnaire has been translated and adapted into Greek by Liakos \u0026amp; Giannitsi in1984 [25] but the validity and reliability check were later carried out by Anagnostopoulou \u0026amp; Kioseoglou [26] in 2002. The S-Anxiety subscales show excellent internal consistency with Cronbach's coefficients of 0.938 and 0.905 respectively.\u003c/p\u003e \u003cp\u003eThe Stressors in Breast Cancer Patients (SBCS) is an innovative tool developed by Cerezo et al. [27] specifically for individuals with breast cancer. The initial questionnaire was developed in Spanish, as the study was conducted in Spain with Spanish-speaking participants. The items were created based on focus groups and interviews with Spanish-speaking breast cancer patients and psycho-oncologists. The psychometric validation of the Stressors in Breast Cancer Scale (SBCS) was also performed using a sample of Spanish women. It considers the unique challenges faced by these patients, including concerns about physical appearance and women's interest in sex. Moreover, the SBCS is designed to be applicable throughout the entire breast cancer journey, from diagnosis to post-treatment survival (health and daily strains, interpersonal difficulties, health care strains and existential concerns such as fear about the future).\u003c/p\u003e \u003cp\u003eMore specifically the researchers identified five key dimensions of stress in breast cancer patients:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAppearance and Sexuality-Related Stress (Physical changes due to treatment (e.g., mastectomy, hair loss) and concerns about femininity and sexual life.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHealth and Daily Life Problems (Physical symptoms and fatigue and limitations in daily activities caused by the illness.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInterpersonal Relationship Issues (Impact on relationships with family, partners, and friends and challenges in managing emotional support).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHealthcare System-Related Stress (Difficulties accessing treatments and medical information and frustrations with the healthcare system\u0026rsquo;s bureaucracy and delays.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWorries and Fears About the Future (Fear of cancer recurrence and uncertainty about life after treatment)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe psychometric properties of the original Spanish scale have been proven and then the scale has been translated into English by Cerezo et al. The SBCS has been translated, cross-culturally adapted and validated in Chinese by Hu et al. [28] and proven a good reliability and validity. Finally, to test for validity of SBCS, we correlated this instrument with two questionnaires: the Perceived Stress Scale (PSS-14) and the State-Trait Anxiety Inventory (STAI). For our study we used only the State-Anxiety (S-Anxiety) subscale measuring the emotion at the specific moment.\u003c/p\u003e \u003cp\u003eThis study aimed to translate the English version of the SBCS into Greek and evaluate its psychometric properties. The goal was to systematically assess the stress levels of breast cancer patients in Greece and provide a solid foundation for developing effective interventions, aiming to reduce stress and enhance their quality of life.\u003c/p\u003e \u003cp\u003eThe SBCS translation was conducted using a forward and backward translation method by two skilled bilingual translators. The Greek version was pre-tested on a pilot study in a small sample of five breast cancer survivors to identify any ambiguities in the scale's content and finalize the translation.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003ePsychometric properties of the SBCS\u003c/h2\u003e \u003cp\u003eThe present study aimed to examine the psychometric properties of the Greek version of the \u003cem\u003eStressors in Breast Cancer Scale\u003c/em\u003e [27]. The SBCS was developed to identify the specific sources of stress experienced by women diagnosed with breast cancer, encompassing both medical and psychosocial aspects of the illness. Given the cultural, linguistic, and healthcare system differences that may influence stress perception and reporting, a rigorous cross-cultural validation was undertaken to ensure the scale\u0026rsquo;s conceptual and metric equivalence in the Greek context. The analysis focused on evaluating the internal structure, reliability, and construct validity of the instrument. Evidence for validity based on internal structure was obtained through exploratory and confirmatory factor analyses, while reliability was assessed using Cronbach\u0026rsquo;s α and McDonald\u0026rsquo;s ω coefficients. Additional validity evidence was gathered by examining the associations between the SBCS and related constructs, including perceived stress, and symptoms of anxiety. This study therefore sought to provide a psychometrically sound Greek version of the SBCS suitable for research and clinical applications among breast cancer survivors.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eInstruments\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eDemographic Questionnaire\u003c/h2\u003e \u003cp\u003eThis includes sociodemographic characteristics data (age, occupation, education level) and disease-related data (type of surgery and Hospital setting, Public or Private)\u003c/p\u003e \u003cp\u003e\u003cb\u003eStressors in Breast Cancer Scale (SBCS).\u003c/b\u003e The SBCS [27] assessed stressors specifically related to the experience of breast cancer. It comprises 24 items related to five theoretical dimensions (physical appearance and sex strains, health and daily difficulties, interpersonal relationship strains, healthcare strains, and worries and concerns about the future), each rated on a 5-point Likert-type scale (1\u0026thinsp;=\u0026thinsp;not at all stressful or is irrelevant to me; 5\u0026thinsp;=\u0026thinsp;very stressful), with higher scores indicating greater perceived stress. One sample item is \u0026lsquo;Finding it hard to take care of people who depend on me (e.g., children, grandchildren, parents)\u0026rsquo;. The SBCS provides both scores for each subscale and a total score representing overall cancer-related stress, by summing the subscale scores. In the present study, the scale was translated and adapted into Greek following international guidelines for cross-cultural adaptation of psychological instruments, including forward and backward translation, expert panel review, and pilot testing for clarity and cultural relevance. The Greek version was then subjected to psychometric validation, replicating the statistical procedures of the original Spanish validation study. In the original development study, Cerezo et al. [27] reported a five-factor structure consistent with the theoretical model and excellent internal consistency, with McDonald\u0026rsquo;s ω and Cronbach\u0026rsquo;s α ranging from .83 to .89 across factors and .95 for the total score. In the current study, the Cronbach\u0026rsquo;s alpha for the total scale was α\u0026thinsp;=\u0026thinsp;.94, indicating high internal consistency.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePSS-14.\u003c/b\u003e The 14-item Perceived Stress Scale [29] assesses the degree to which situations in one's life are appraised as stressful over the past month. Items are rated on a 5-point frequency scale ranging from 0 (never) to 4 (very often). The scale includes seven positively worded items that are reverse-scored and seven negatively worded items that are scored directly. Total scores range from 0 to 56, with higher scores indicating higher levels of perceived stress. The Greek version has shown adequate reliability [24]. In the current study, the Cronbach\u0026rsquo;s alpha for the total scale was α\u0026thinsp;=\u0026thinsp;.88, indicating high internal consistency.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSTAI.\u003c/b\u003e Each section of the assessment (State and Trait) has a possible score of 20 to 80. In general, higher scores indicate more severe anxiety. Some items on the assessment are reverse scored to account for positively worded items. For that reason, certain questions are scored in reverse There\u0026rsquo;s no universal cutoff for anxiety levels as with other tests, but State Trait Anxiety Inventory scores could be grouped as:\u003c/p\u003e \u003cp\u003e20\u0026ndash;37: Low anxiety\u003c/p\u003e \u003cp\u003e38\u0026ndash;44: Moderate anxiety\u003c/p\u003e \u003cp\u003e45\u0026ndash;80: High anxiety\u003c/p\u003e \u003cp\u003eSeveral items on the STAI were reversed coded\u003c/p\u003e \u003cp\u003eRecommended for studying anxiety in research and clinical settings.\u003c/p\u003e \u003cp\u003eIn the current study, the Cronbach\u0026rsquo;s alpha for the total scale was α\u0026thinsp;=\u0026thinsp;.96, indicating high internal consistency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were conducted using IBM SPSS Statistics (Version 25; IBM Corp., 2017) and R (Version 4.3.1; R Core Team, 2023). The lavaan package [30] was used for confirmatory factor analysis (CFA) and structural equation modeling procedures.\u003c/p\u003e \u003cp\u003eDescriptive statistics (means, standard deviations, skewness, and kurtosis) were first calculated for all 24 SBCS items to examine score distributions and assess normality. Skewness and kurtosis values within \u0026plusmn;\u0026thinsp;2 were considered acceptable indicators of normality.\u003c/p\u003e \u003cp\u003eTo obtain validity evidence based on the internal structure, an exploratory factor analysis (EFA) was conducted using the minimum residuals extraction method with oblimin rotation. Factor retention was guided by parallel analysis and theoretical interpretability. Sampling adequacy was verified with the Kaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) index and Bartlett\u0026rsquo;s test of sphericity. Because the sample size (N\u0026thinsp;=\u0026thinsp;216) did not permit random division into two independent subsamples, the EFA and subsequent confirmatory factor analysis (CFA) were conducted sequentially on the same dataset. This sequential approach, while methodologically suboptimal compared to split-sample designs, has been documented as a pragmatic strategy in psychometric validation studies with modest samples where random division is not feasible [31] [32]. Readers should interpret the CFA results as an assessment of consistency between the empirical structure and the theoretical model, rather than as a fully independent cross-validation.\u003c/p\u003e \u003cp\u003eThe CFA tested a second-order, five-factor structure representing the following dimensions: physical appearance and sex strains, health and daily difficulties, interpersonal relationship strains, healthcare strains, and worries and concerns about the future. Model fit was evaluated using the chi-square statistic (χ\u0026sup2;), comparative fit index (CFI), Tucker\u0026ndash;Lewis index (TLI), root mean square error of approximation (RMSEA) with 90% confidence intervals, and standardized root mean square residual (SRMR). Acceptable model fit was defined as CFI and TLI \u0026ge; .90 and RMSEA \u0026le; .08 [33].\u003c/p\u003e \u003cp\u003eInternal consistency was examined using Cronbach\u0026rsquo;s α and McDonald\u0026rsquo;s ω, with values \u0026ge; .70 considered satisfactory [32]. Composite reliability (CR) and average variance extracted (AVE) were also calculated to assess convergent validity, with thresholds of .70 and .50, respectively [34]. Discriminant validity was examined by comparing the square roots of AVE values with the inter-factor correlations.\u003c/p\u003e \u003cp\u003eValidity evidence based on relationships with other variables was assessed through Pearson\u0026rsquo;s correlations between SBCS scores and the Perceived Stress Scale (PSS-14) and State\u0026ndash;Trait Anxiety Inventory (STAI). Correlation magnitudes of |.10|, |.30|, and |.50| were interpreted as small, moderate, and large, respectively [35].\u003c/p\u003e \u003cp\u003eMissing Data: The dataset was complete with no missing values for any of the study variables (SBCS, PSS-14, STAI, or demographic information). All 216 participants included in the analyses had complete data across all measures.\u003c/p\u003e \u003cp\u003eFinally, descriptive statistics (means, standard deviations, skewness, and kurtosis) were computed for the five SBCS dimensions and the total score to provide an overall indicator of cancer-related stress.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive Statistics\u003c/h2\u003e \u003cp\u003eDescriptive statistics for each item of the SBCS are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Item means ranged from 1.85 to 3.75 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.13\u0026ndash;1.54). Skewness and kurtosis values were within acceptable limits (\u0026plusmn;\u0026thinsp;2), indicating no severe deviations from normality.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean (M), standard deviation (SD), and skewness and kurtosis for items of the SBCS (N\u0026thinsp;=\u0026thinsp;216)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSkewness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKurtosis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;1.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe total SBCS demonstrated excellent internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.94; McDonald\u0026rsquo;s ω\u0026thinsp;=\u0026thinsp;.95). Item\u0026ndash;total correlations ranged from .46 to .75, indicating adequate homogeneity among items.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eExploratory Factor Analysis\u003c/h2\u003e \u003cp\u003eGiven that the sample size did not permit random division into two independent subsamples, the exploratory and confirmatory analyses were performed sequentially on the same dataset. This approach has been applied in previous scale validation studies with comparable samples [32].\u003c/p\u003e \u003cp\u003eAn exploratory factor analysis (EFA) using the minimum residuals extraction method with oblimin rotation and parallel analysis supported a five-factor solution consistent with the theoretical model of the SBCS (physical appearance and sex strains, health and daily difficulties, interpersonal relationship strains, healthcare strains, and worries and concerns about the future). The results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The Kaiser\u0026ndash;Meyer\u0026ndash;Olkin index was .92, and Bartlett\u0026rsquo;s test of sphericity was significant, χ\u0026sup2;(276)\u0026thinsp;=\u0026thinsp;3409.03, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, confirming sampling adequacy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactor loadings (above 0.30) from the EFA of the SBCS (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;216).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.496\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.654\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.737\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.569\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.768\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.832\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.484\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.438\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.653\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS14\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.672\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS16\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.368\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS19\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.835\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS20\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.811\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS21\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.731\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS22\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS23\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.640\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBCS24\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.912\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote.\u003c/em\u003e F1\u0026thinsp;=\u0026thinsp;Health and daily difficulties (SBCS5\u0026ndash;9, 10, 12), F2\u0026thinsp;=\u0026thinsp;Worries and concerns about the future (SBCS20\u0026ndash;24), F3\u0026thinsp;=\u0026thinsp;Healthcare strains (SBCS15\u0026ndash;19), F4\u0026thinsp;=\u0026thinsp;Interpersonal relationship strains (SBCS11, 13, 14), F5\u0026thinsp;=\u0026thinsp;Physical appearance and sex strains (SBCS1\u0026ndash;4)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eConfirmatory Factor Analysis\u003c/h2\u003e \u003cp\u003eGiven the modest sample size, the exploratory factor analysis revealed minor deviations from the original structure - for example, certain items (e.g., SBCS10) showed higher loadings on different factors compared to the theoretical configuration proposed by Cerezo et al. [27]. To evaluate whether these empirical differences represented meaningful structural variations or sample-related fluctuations, two hierarchical models were tested: one based on the original Spanish five-factor structure and one reflecting the empirical loadings observed in the present data.\u003c/p\u003e \u003cp\u003eThe original structure, based on the Spanish validation by Cerezo et al. [27], provided a slightly better fit, χ\u0026sup2;(247)\u0026thinsp;=\u0026thinsp;565.18, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, CFI = .89, TLI = .87, RMSEA = .08, SRMR = .07 (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), than the revised model, χ\u0026sup2;(247)\u0026thinsp;=\u0026thinsp;644.89, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, CFI = .88, TLI = .87, RMSEA = .09, SRMR = .08. The difference in model fit was minimal (ΔCFI = .007; ΔRMSEA = .009), but the original configuration offered a more parsimonious and theoretically coherent representation of the construct. Therefore, the original five-factor second-order model was retained for subsequent analyses.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGoodness-of-fit indices for the second-order factor model of the SBCS (N\u0026thinsp;=\u0026thinsp;216).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTLI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRMSEA (90% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSRMR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e565.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.886\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.083 [.074, .092]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUsing robust maximum likelihood estimation (MLR), the retained model showed an acceptable fit: χ\u0026sup2;(247)\u0026thinsp;=\u0026thinsp;565.18, p \u0026lt; .001, CFI = .89, TLI = .87, RMSEA = .08 [90% CI = .07, .09], SRMR = .07. All standardized factor loadings were significant (p \u0026lt; .001) and ranged from .63 to .91, supporting the hypothesized hierarchical structure.\u003c/p\u003e \u003cp\u003eAlthough CFI and TLI values were marginally below conventional cutoffs, the remaining indices (RMSEA, SRMR) indicated a satisfactory model fit. The five first-order factors\u0026mdash;representing physical appearance and sex strains, health and daily difficulties, interpersonal relationship strains, healthcare strains, and worries and concerns about the future, loaded significantly on a higher-order general stress factor (β\u0026thinsp;=\u0026thinsp;.72\u0026ndash;.92). These results align with the Spanish validation study and support the factorial validity of the Greek version of the SBCS.\u003c/p\u003e \u003cp\u003eThe standardized second-order confirmatory factor model for the Greek version of the Stressors in Breast Cancer Scale (SBCS) is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The model includes one higher-order factor (\u003cem\u003eG\u003c/em\u003e\u0026thinsp;=\u0026thinsp;general stress) and five first-order factors representing (F1) physical appearance and sex strains, (F2) health and daily difficulties, (F3) interpersonal relationship strains, (F4) healthcare strains, and (F5) worries and concerns about the future. All paths were statistically significant (\u003cem\u003ep\u003c/em\u003e \u0026lt; .001).\u003c/p\u003e \u003cp\u003eAlthough CFI and TLI values were slightly below conventional thresholds, they approached acceptable levels, particularly given the complexity of the model and sample size.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003eStandardized path coefficients are displayed. G\u0026thinsp;=\u0026thinsp;general stress; F1\u0026ndash;F5\u0026thinsp;=\u0026thinsp;first-order factors corresponding to the five SBCS dimensions.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eReliability and Convergent Validity\u003c/h2\u003e \u003cp\u003eInternal consistency was excellent across all dimensions (α\u0026thinsp;=\u0026thinsp;.80\u0026ndash;.89; ω\u0026thinsp;=\u0026thinsp;.82\u0026ndash;.90) and for the total scale (α\u0026thinsp;=\u0026thinsp;.94; ω\u0026thinsp;=\u0026thinsp;.95). Convergent validity was confirmed with Average Variance Extracted (AVE = .56\u0026ndash;.68) and Composite Reliability (CR = .82\u0026ndash;.90) values exceeding recommended thresholds (.50 and .70, respectively) [34]. Results are demonstrated in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eItem\u0026ndash;factor correlations, corrected item\u0026ndash;total correlations, McDonald\u0026rsquo;s ω, Cronbach\u0026rsquo;s α, and average variance extracted (AVE) for the five factors and total score of the SBCS (N\u0026thinsp;=\u0026thinsp;216).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS factor / items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItem\u0026ndash;factor correlation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorrected item\u0026ndash;total correlation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCronbach\u0026rsquo;s α\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMcDonald\u0026rsquo;s ω\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAVE\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical appearance and sex strains (F1)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth and daily difficulties (F2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInterpersonal relationship strains (F3)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealthcare strains (F4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWorries and concerns about the future (F5)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal score SBCS (G)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026mdash;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026mdash;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote. α\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Cronbach\u0026rsquo;s alpha; \u003cem\u003eω\u003c/em\u003e\u0026thinsp;=\u0026thinsp;McDonald\u0026rsquo;s omega; AVE\u0026thinsp;=\u0026thinsp;Average Variance Extracted.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDiscriminant validity was also supported, as the square roots of the AVE values for each factor were greater than the inter-factor correlations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eValidity Evidence Based on Relationships with Other Variables\u003c/h2\u003e \u003cp\u003eTo examine convergent validity with related constructs, Pearson correlations were calculated between SBCS scores and measures of perceived stress (PSS-14) and anxiety (STAI). As expected, SBCS total scores correlated positively and strongly with both perceived stress (\u003cem\u003er\u003c/em\u003e = .65, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) and anxiety (\u003cem\u003er\u003c/em\u003e = .67, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001).\u003c/p\u003e \u003cp\u003eIn the original validation by Cerezo et al. [27], measurement invariance was examined across groups defined by time since diagnosis (\u0026lt;\u0026thinsp;3 years vs. \u0026ge;3 years). In the present study, given the smaller total sample size (N\u0026thinsp;=\u0026thinsp;216), the data were analyzed as a single group to ensure model stability and sufficient statistical power. Therefore, measurement invariance analyses were not performed at this stage. Future research with larger and more balanced samples should further examine the invariance of the SBCS across relevant clinical subgroups.\u003c/p\u003e \u003cp\u003eCorrelations between SBCS subscales and external measures are presented in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between SBCS factor and total scores and scores on perceived stress and anxiety (N\u0026thinsp;=\u0026thinsp;216).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical appearance and sex strains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth and daily difficulties\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterpersonal relationship strains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealthcare strains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWorries and concerns about the future\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal score SBCS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived stress (PSS-14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.48***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.45***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.56***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.53***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.62***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.65***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety (STAI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.48***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.46***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.50***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.66***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.67***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003eNote.\u003c/b\u003e SBCS\u0026thinsp;=\u0026thinsp;Stress in Breast Cancer Scale; PSS-14\u0026thinsp;=\u0026thinsp;Perceived Stress Scale (14-item version); STAI\u0026thinsp;=\u0026thinsp;State\u0026ndash;Trait Anxiety Inventory.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThese findings indicate that higher cancer-specific stress is associated with greater general stress and anxiety, providing strong evidence for convergent validity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive Statistics for SBCS Dimensions\u003c/h2\u003e \u003cp\u003eDescriptive statistics for the SBCS subscales and total score are presented in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e. The worries and concerns about the future subscale showed the highest mean score, followed by health and daily difficulties.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMeans, standard deviations, and skewness and kurtosis for scores on the SBCS (its five dimensions and total; N\u0026thinsp;=\u0026thinsp;216) calculated as the sum of the respective items.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCS scores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSkewness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKurtosis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical appearance and sex strains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;1.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth and daily difficulties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;1.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterpersonal relationship strains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare strains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorries and concerns about the future\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;1.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal score SBCS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNote.\u003c/b\u003e \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Mean; \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Standard deviation. Scores correspond to the sum of each subscale\u0026rsquo;s items.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, the findings support the structural coherence and internal consistency of the SBCS-GR.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the psychometric properties of the Greek version of the Stressors in Breast Cancer Scale (SBCS) [27]. The SBCS was designed to identify specific sources of stress in women diagnosed with breast cancer such as medical, psychosocial, and existential dimensions of the illness. Cross-cultural validation was necessary to ensure conceptual and metric equivalence in the Greek context, given differences in culture, language, and healthcare systems that may influence how stress is both perceived and reported. The present study aimed to evaluate the psychometric properties of the SBCS in a Greek sample. The findings support a five-factor structure consistent with the original model, alongside high internal consistency and strong associations with related constructs. Importantly, the availability of a culturally adapted instrument enables more precise assessment of patient needs in Greek oncology settings, where psychosocial screening tools remain limited.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eOverview of Findings\u003c/h2\u003e \u003cp\u003eThe Greek SBCS showed satisfactory psychometric properties across multiple validity domains. These findings align with the transactional model of stress, suggesting that breast cancer-related stress is multidimensional and influenced by both internal appraisals and contextual factors.\u003c/p\u003e \u003cp\u003eExploratory factor analysis supported a five-factor structure consistent with the original Spanish validation: physical appearance and sex strains, health and daily difficulties, interpersonal relationship strains, healthcare strains, and worries and concerns about the future. Confirmatory factor analysis provided additional support for a second-order hierarchical model, with fit indices (CFI = .89, TLI = .87, RMSEA = .08, SRMR = .07).\u003c/p\u003e \u003cp\u003eInternal consistency was excellent for the total scale (α\u0026thinsp;=\u0026thinsp;.94, ω\u0026thinsp;=\u0026thinsp;.95) and individual subscales (α\u0026thinsp;=\u0026thinsp;.80\u0026ndash;.89, ω\u0026thinsp;=\u0026thinsp;.82\u0026ndash;.90), comparable to both the Spanish (α\u0026thinsp;=\u0026thinsp;.94) and Chinese (α\u0026thinsp;=\u0026thinsp;.938) validations. Convergent validity was demonstrated through strong correlations with perceived stress (PSS-14: r = .65) and anxiety (STAI: r = .67), showing that cancer-specific stressors measured by the SBCS relate meaningfully to general psychological distress. Discriminant validity was confirmed, as the square roots of AVE values exceeded inter-factor correlations, indicating that the five dimensions capture distinct yet related aspects of breast cancer-related stress.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eComparison with Spanish and Chinese Validations\u003c/h2\u003e \u003cp\u003eThe replication of the original factor structure supports the cross-cultural robustness of the SBCS and highlights its applicability beyond the populations in which it was initially developed. Our findings replicate the psychometric properties reported in both the Spanish [27] and Chinese [28] validations. All three studies yielded a five-factor second-order structure with comparable factor loadings and excellent internal consistency. Finding the same five-factor structure in Spain, China, and now Greece suggests this stress domains reflect common experiences across different cultures. However, we observed some cross-cultural variations in the factorial structure. In our Greek sample, item SBCS10 (\"Being restricted in going out with friends\") loaded more strongly on the health and daily difficulties factor than on the interpersonal relationship strains factor. This may reflect cultural differences in how social restrictions are understood\u0026mdash;Greek women with breast cancer may view reduced social engagement primarily as a consequence of physical limitations rather than relational strain. The Chinese validation showed similar patterns, with items 10 and 12 reassigned to the daily difficulties factor [28].\u003c/p\u003e \u003cp\u003eThese structural differences, yet subtle, highlight the importance of cultural adaptation in psycho-oncology research. Western cultures may emphasize interpersonal relationships as a distinct stressor domain, whereas Greek and Chinese cultures may integrate social restrictions more closely with physical and functional limitations. Despite these differences, the overall theoretical framework remained the same across all three validations, supporting the SBCS's cross-cultural applicability.\u003c/p\u003e \u003cp\u003eOur goodness-of-fit indices (CFI = .89, TLI = .87) were somewhat lower than those reported in the Chinese validation (CFI = .93, TLI = .91) but comparable to those from other validation studies using similar sample sizes. The Spanish validation study did not report specific fit indices, making direct comparison difficult. Importantly, RMSEA (.08) and SRMR (.07) were within acceptable thresholds, and all factor loadings were statistically significant (ranging from .63 to .91, all p \u0026lt; .001), supporting the structural validity of the Greek SBCS. The slightly lower CFI and TLI values should be interpreted in context: our factor loadings were as strong as those reported in larger validation studies, and the hierarchical model demonstrated clear conceptual coherence. Simulation studies demonstrate that incremental fit indices (CFI, TLI) are systematically attenuated in samples smaller than 250, with RMSEA and SRMR showing greater robustness across sample sizes [36]. Accordingly, RMSEA (.08) and SRMR (.07), both within acceptable thresholds, are treated as primary indicators of model fit and our values still fall within ranges considered acceptable by contemporary structural equation modeling standards [37]. The strong factor loadings, combined with excellent internal consistency and meaningful construct validity associations, provide compelling evidence for the measure's structural integrity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eClinical Utility and Implementation\u003c/h2\u003e \u003cp\u003eFrom a clinical perspective, the SBCS-GR may serve as a practical screening tool for identifying specific domains of distress, allowing healthcare professionals to tailor psychosocial interventions more effectively.Systematic psychosocial screening remains unused in Greek oncology settings, despite international recommendations for routine distress screening. The Greek healthcare system has faced significant challenges in recent decades due to the economic crisis and the Pandemic, affecting cancer care delivery and limiting access to psycho-oncology services [38]. Therefore, brief, validated screening scales are essential for identifying patients who would benefit from specialist psycho-oncology care.\u003c/p\u003e \u003cp\u003eThe multidimensional structure of the SBCS-GR has direct implications for clinical decision-making. Patients who score high on the appearance and sexuality dimension (Items 1\u0026ndash;4) are experiencing significant distress related to treatment-related physical changes and may benefit from body image counseling, psychosexual therapy, or consultation with plastic surgeons regarding reconstruction options. In contrast, women showing elevated scores on health and daily functioning difficulties (Items 5\u0026ndash;9) are struggling primarily with symptom burden and functional limitations. For these patients, oncology teams might prioritize referrals to physiotherapy, or fatigue management programs rather than psychological counseling.\u003c/p\u003e \u003cp\u003eThe interpersonal relationship area (Items 10\u0026ndash;14) identifies a different group of clinical needs. Women scoring high in this field are experiencing stress in their family relationships and caregiving roles and difficulties with emotional expression. These patients would benefit from couples therapy, family counseling, or communication skills training.\u003c/p\u003e \u003cp\u003eIn the same way, the healthcare system navigation dimension (Items 15\u0026ndash;19) points stressors related to appointment scheduling, treatment coordination, information gaps and anxiety due to medical bureaucracy. Patients struggling in this area require practical support such as patient navigator services, treatment information help desk or healthcare advocacy instead of psychological support. Finally, the worries and concerns about the future dimension (Items 20\u0026ndash;24), which presented the highest mean scores in our sample, identifies women experiencing fear of cancer recurrence and existential distress. These patients are more likely to benefit from cognitive-behavioural interventions or meaning-centered psychotherapy addressing existential concerns.\u003c/p\u003e \u003cp\u003eWhat differentiates the SBCS from generic distress measures is that the SBCS identifies which particular stressors are generating that distress. In that way, clinicians are guided towards appropriate, personalized and effective referral decisions. A woman scoring high on appearance concerns but low on future worries requires fundamentally different support than one with the reverse profile, even if both might score similarly on a generic anxiety item.\u003c/p\u003e \u003cp\u003eFrom a practical implementation viewpoint, the SBCS is feasible for routine clinical use. Its administration takes approximately five to seven minutes and can be completed in a waiting room using either e-form or paper formats. In healthcare contexts like the Greek public health system lacking resources, the SBCS allows allocation of limited psycho-oncology care by matching patients to the services needed. This approach represents a shift from reactive crisis intervention towards preventive and supportive care.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eCultural Context and Healthcare System Considerations\u003c/h2\u003e \u003cp\u003eThe Greek validation provides insight into how cultural values and healthcare system characteristics may influence the experience and reporting of cancer-related stressors. Greece is characterized by strong family structures, good social support networks, and high levels of family involvement in healthcare decision-making [39]. These cultural factors may partially explain why interpersonal relationship strains yielded lower scores compared to other dimensions.\u003c/p\u003e \u003cp\u003eThe Greek healthcare system has experienced significant challenges in recent decades, affecting cancer care delivery and patient psychological support. Economic constraints have limited access to specialized psycho-oncology services, with fewer than 20% of cancer centers providing systematic psychological assessment and support [38]. This gap makes the availability of brief, validated screening instruments particularly important for identifying women who might benefit from psychological intervention. While Greek translations exist for generic stress and anxiety measures, there is a notable absence of cancer-specific stress assessment instruments validated for the Greek population. This validation addresses a critical need for culturally appropriate, disease-specific assessment in Greek oncology settings.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eClinical and Research Implications\u003c/h2\u003e \u003cp\u003eA psychometrically sound Greek version of the SBCS has significant implications for both clinical practice and research. Clinically, the SBCS can serve as a brief (5\u0026ndash;7 minute) screening tool integrated into routine oncology care, enabling systematic identification of specific stress domains requiring intervention. Given that 40\u0026ndash;60% of breast cancer patients experience clinically significant psychological distress yet fewer than 30% receive psychosocial support [7], systematic screening with domain-specific assessment represents a critical gap in Greek oncology care. The SBCS's five-factor structure allows oncology teams to move beyond generic distress screening toward precision-matched interventions: women scoring high on physical appearance and sexuality strains (subscale mean\u0026thinsp;\u0026gt;\u0026thinsp;3.5 on 5-point scale) may benefit from evidence-based body image interventions or sexual rehabilitation programs integrated into survivorship care, whereas those with elevated scores on worries and concerns about the future may require cognitive-behavioral therapy targeting fear of cancer recurrence\u0026mdash;an intervention shown to reduce fear by 40\u0026ndash;50% in randomized trials [18].\u003c/p\u003e \u003cp\u003e The SBCS enables oncology teams to implement tailored, stepped-care models. Patients with low-to-moderate total SBCS scores (below sample median) may benefit from psychoeducational resources and peer support groups, while those scoring above the 75th percentile require referral to specialized psycho-oncology services. This stratification approach maximizes limited mental health resources while ensuring high-need patients receive intensive intervention. Multidisciplinary oncology teams can use SBCS subscale profiles to coordinate care: physical therapists addressing body image concerns (physical appearance subscale), social workers facilitating healthcare navigation (health system subscale), and psychologists targeting future-oriented anxiety (worries subscale). Such coordinated care models have demonstrated 30\u0026ndash;40% reductions in psychological distress and improved treatment adherence in breast cancer populations [22].\u003c/p\u003e \u003cp\u003eThe SBCS can inform culturally adapted psychosocial interventions. Given that worries about the future emerged as the most prominent stressor in our sample (M\u0026thinsp;=\u0026thinsp;3.82, highest subscale mean), interventions targeting fear of cancer recurrence may be particularly relevant for Greek populations. International data suggest fear of recurrence affects 50\u0026ndash;70% of breast cancer survivors and is associated with reduced quality of life, increased healthcare utilization, and poorer treatment adherence [11]. The moderate scores on interpersonal relationship strains (M\u0026thinsp;=\u0026thinsp;2.45) suggest that family-centered interventions, which leverage existing strong family support networks while addressing potential areas of relational tension, may be well-suited to the Greek cultural context where family involvement in cancer care is normative.\u003c/p\u003e \u003cp\u003eFrom a research perspective, the SBCS enables cross-cultural comparisons of cancer-related stressors across the Spanish [27], Chinese [28], and now Greek validations, facilitating identification of universal versus culture-specific sources of distress. Preliminary cross-cultural data suggest physical appearance concerns are universally elevated (M\u0026thinsp;\u0026gt;\u0026thinsp;3.5 across all three validations), whereas interpersonal relationship strains show cultural variation (higher in collectivist cultures), informing culturally responsive intervention development. Longitudinal studies using the SBCS could examine trajectories of stress across the cancer continuum, from diagnosis through treatment, survivorship, and potential recurrence. Such research could identify critical time points when specific stressors peak\u0026mdash;existing literature suggests physical appearance concerns peak during active treatment (chemotherapy-related hair loss, surgical changes), while future worries intensify at treatment completion when medical surveillance decreases [19]\u0026mdash;informing optimal timing of psychosocial interventions.\u003c/p\u003e \u003cp\u003eThe SBCS can evaluate the efficacy of stress-reduction interventions in Greek populations. By administering the scale before and after intervention, researchers can assess changes in specific stressor domains and determine which interventions are most effective for which types of stress\u0026mdash;for example, whether mindfulness-based interventions preferentially reduce future-oriented worry versus present-focused physical concerns. The SBCS could also serve as a mediator variable in studies examining whether reducing cancer-specific stress mediates the relationship between psychosocial interventions and health outcomes such as quality of life (demonstrated effect sizes d\u0026thinsp;=\u0026thinsp;0.4\u0026ndash;0.6 in meta-analyses), treatment adherence, immune function markers, and disease progression. Such mechanistic research could elucidate pathways through which psychosocial interventions improve cancer outcomes, strengthening the evidence base for integrating mental health care into standard oncology practice.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eAlthough the use of a single sample for both EFA and CFA may limit strict cross-validation, this approach has been adopted in similar psychometric studies with moderate sample sizes.\u003c/p\u003e \u003cp\u003eThe primary limitation is sample size (N\u0026thinsp;=\u0026thinsp;216). While adequate for EFA and CFA according to recommended subject-to-item ratios, the sample size precluded certain advanced psychometric analyses. Specifically, measurement invariance across clinically relevant subgroups (e.g., time since diagnosis, treatment type, disease stage) could not be examined due to insufficient subsample sizes. The Chinese validation [28], with a larger sample (N\u0026thinsp;=\u0026thinsp;878), demonstrated measurement invariance across time since diagnosis (\u0026lt;\u0026thinsp;3 years vs. \u0026ge;3 years), suggesting that the SBCS structure remains stable across disease trajectory. Future Greek studies with larger samples should prioritize this analysis to ensure that SBCS scores are comparable across different clinical subpopulations.\u003c/p\u003e \u003cp\u003eWe did not assess test-retest reliability in this study. This decision reflects the nature of what the SBCS measures. The scale assesses stressors\u0026mdash;external demands and challenges that women with breast cancer face\u0026mdash;rather than stable personality traits. These stressors naturally change as patients move through their cancer journey. Treatment side effects come and go, relationships shift, fears about the future fluctuate, and healthcare interactions vary. Asking patients to complete the same questionnaire twice within a short period would not tell us whether the scale is reliable. Instead, it would likely show us that their actual stressors had changed, which is exactly what we would expect. This is different from measuring something like anxiety proneness or coping style, which tend to be more stable over time. Both the original Spanish validation and the Chinese validation made the same decision not to include test-retest assessment, suggesting this is a recognized consideration for instruments that measure changing experiences rather than stable characteristics. This approach is consistent with recommendations for instruments measuring dynamic, state-like experiences rather than stable traits, for which internal consistency and construct validity constitute more meaningful psychometric evidence than temporal stability [31]. What matters more for a scale like this is whether it consistently measures the construct at a single point in time (internal consistency) and whether it relates to other relevant measures in expected ways (construct validity). Our analyses showed strong evidence for both of these properties.\u003c/p\u003e \u003cp\u003eConvenience sampling and recruitment primarily through cancer support associations and a private hospital may have introduced selection bias. Participants were predominantly urban, well-educated (70% with university degrees), and employed (68%), which may limit generalizability to rural, lower-educated, or economically disadvantaged populations. The majority of participants (66%) received care in private hospitals, which may reflect higher socioeconomic status and differential healthcare experiences compared to those relying exclusively on public healthcare. Future research should prioritize recruitment from diverse geographical regions and healthcare settings. Moreover, time since diagnosis was not systematically collected as a demographic variable, limiting our ability to examine potential variations in stressor patterns across different stages of the disease trajectory.\u003c/p\u003e \u003cp\u003eThe study also has notable strengths that support confidence in the findings. Our sample of 216 women exceeds the recommended minimum of 200 participants for confirmatory factor analysis and provides adequate statistical power for the primary psychometric analyses conducted. We assessed multiple forms of validity (convergent, discriminant) rather than relying solely on factor structure, and followed established international guidelines [17] for translation and cross-cultural adaptation. The rigorous forward-backward translation process, combined with cognitive interviews and pilot testing, ensured conceptual equivalence rather than mere literal translation. Perhaps most importantly, our findings closely replicate results from both the Spanish original and Chinese validation studies, despite substantial differences in sample sizes (N\u0026thinsp;=\u0026thinsp;455, N\u0026thinsp;=\u0026thinsp;879, N\u0026thinsp;=\u0026thinsp;216), recruitment settings, and cultural contexts. This pattern of consistent structural replication across three linguistically and culturally distinct populations\u0026mdash;Southern European, East Asian, and Southeastern European\u0026mdash;provides robust evidence that the SBCS captures fundamental dimensions of breast cancer-related stress that generalize across diverse contexts. The convergence of findings strengthens confidence that observed relationships reflect true psychometric properties rather than sample-specific artifacts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eFuture Directions\u003c/h2\u003e \u003cp\u003eSeveral critical research directions emerge from this validation, each addressing specific methodological limitations while advancing understanding of cancer-related stress in Greek populations. Future studies should examine test\u0026ndash;retest reliability and replicate the findings in more diverse and clinical samples\u003c/p\u003e \u003cp\u003eComprehensive validation requires independent replication with larger, more diverse samples recruited through probability-based methods. Our convenience sample (N\u0026thinsp;=\u0026thinsp;216), while adequate for preliminary factor structure examination, limits generalizability and statistical power for advanced analyses. Future studies should employ stratified random sampling from cancer registries to ensure representation across disease stages (early-stage vs. metastatic), treatment modalities (surgery-only vs. combined treatments), age cohorts, geographic regions (urban Athens vs. rural areas), and socioeconomic strata. Sample sizes of 400\u0026ndash;500 would enable measurement invariance analyses to ensure that SBCS scores are comparable across these clinically relevant subgroups\u0026mdash;a prerequisite for meaningful group comparisons, identification of high-risk populations, and longitudinal research examining stress trajectories across the cancer continuum.\u003c/p\u003e \u003cp\u003eEstablishing test-retest reliability represents an urgent priority absent from this study. Without temporal stability data, we cannot distinguish true change in stressor exposure from measurement error, limiting the SBCS's utility for monitoring individual patients over time or evaluating intervention efficacy. A 2- to 4-week test-retest interval is recommended, as this timeframe is sufficiently long to reduce memory effects but short enough to minimize genuine change in stressor exposure. Intraclass correlation coefficients \u0026ge;\u0026thinsp;.70 would indicate acceptable stability for clinical use. Future research should also examine responsiveness to change following psychosocial interventions, establishing minimal clinically important differences for total and subscale scores to guide intervention evaluation and clinical decision-making.\u003c/p\u003e \u003cp\u003eAddressing the same-sample exploratory and confirmatory factor analysis conducted in this study requires independent cross-validation. Ideally, future research should employ a three-sample design: an initial exploratory sample (n\u0026thinsp;~\u0026thinsp;300) for factor structure examination, an independent confirmatory sample (n\u0026thinsp;~\u0026thinsp;300) for model testing, and a third validation sample (n\u0026thinsp;~\u0026thinsp;300) for invariance testing and criterion validity assessment. This design overcomes the statistical dependencies and potential overfitting inherent in conducting EFA and CFA on identical data, providing more robust evidence of structural validity. Multi-group CFA across samples would test factorial invariance, establishing whether the five-factor structure replicates consistently or requires culture-specific modifications.\u003c/p\u003e \u003cp\u003eBeyond psychometric refinement, mitigating self-report bias requires multi-method validation. Exclusive reliance on self-report measures in this study introduces shared method variance, potentially inflating correlations with other self-report instruments (e.g., PSS, STAI) and raising concerns about social desirability bias, particularly for sensitive items addressing interpersonal relationship strains or healthcare system frustrations. Future research should incorporate objective indicators (medical records data on treatment adherence, healthcare utilization patterns), clinician-rated assessments (oncologist or nurse ratings of patient distress), behavioral measures (cortisol levels as physiological stress markers, actigraphy-measured sleep disruption), and significant-other reports (partner or family member assessments of patient stress) to establish convergent validity across methods. Discrepancies between self-report and objective measures could reveal important insights into awareness, denial, or communication patterns requiring clinical attention.\u003c/p\u003e \u003cp\u003eA complementary qualitative approach could deepen understanding of Greek women's lived experiences of cancer-related stressors. Focus groups or in-depth phenomenological interviews could uncover culturally specific stressors not fully captured by the SBCS's Spanish-origin item pool\u0026mdash;for example, concerns about burdens on extended family networks prevalent in collectivist Greek culture, navigation challenges within Greece's complex public-private healthcare system, economic stressors related to treatment costs and work disruption particularly salient during economic instability, or spiritual and religious dimensions of cancer-related distress. Such qualitative data could inform development of culture-specific supplementary items, enhancing the SBCS's cultural validity and clinical utility in Greek contexts.\u003c/p\u003e \u003cp\u003eEqually important is examining potential moderators and mediators of the relationship between SBCS scores and psychological outcomes. Social support quality and quantity, active versus avoidant coping strategies, personality traits (resilience, neuroticism, optimism), healthcare system factors (continuity of care, patient-provider communication quality, access to psychosocial services), and socioeconomic resources may buffer or exacerbate the impact of cancer-specific stressors on anxiety, depression, and quality of life. Identifying these moderators through moderated regression or structural equation modeling would enable development of targeted interventions\u0026mdash;for example, social support interventions for isolated patients with high interpersonal relationship strain, or healthcare navigation assistance for those scoring high on health system stress. Mediation analyses could test whether reducing specific stressor domains (e.g., future worries via fear of recurrence interventions) mediates improvements in broader mental health outcomes, elucidating mechanisms of psychosocial intervention efficacy.\u003c/p\u003e \u003cp\u003eSystematic cross-cultural comparisons using the SBCS across countries where validation has been completed (Spain, China, Greece) or is underway could illuminate universal versus culture-specific aspects of cancer-related stress. Multi-national datasets would enable tests of measurement invariance across cultures, determining whether the five-factor structure holds universally or requires culture-specific modifications. Cross-cultural mean comparisons (with appropriate invariance testing) could reveal whether certain stressor domains (e.g., physical appearance concerns, healthcare system navigation) are universally elevated or show cultural variation, informing development of globally applicable versus culturally tailored psychosocial interventions. Such research could also examine whether relationships between SBCS scores and outcomes (quality of life, treatment adherence, survival) are culturally invariant or moderated by cultural values, healthcare system characteristics, or social support norms.\u003c/p\u003e \u003cp\u003eAddressing these methodological limitations and pursuing these research directions would transform the SBCS from a promising instrument into a comprehensively validated, culturally sensitive, clinically actionable tool for assessment and intervention in Greek breast cancer care.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the SBCS-GR demonstrates satisfactory psychometric properties and offers a promising tool for assessing multidimensional stress in breast cancer patients. Its use may enhance both clinical screening and research in psycho-oncology in Greek populations. This validation has important implications for clinical use in Greece. Multidisciplinary oncology teams now rely only on generic distress measures that identify whether a patient is stressed but provide little guidance about the distress nature. The SBCS-GR changes this by indicating specific stressors such as appearance concerns, physical symptoms, relationship difficulties, healthcare navigation problems, or fear of recurrence. This information matters because different stressors require different interventions. A woman distressed primarily by body image changes due to a mastectomy needs different support than one whose main concern is finding the pathway to the healthcare system or facing fear of disease recurrence.\u003c/p\u003e \u003cp\u003eThis specificity is considered particularly valuable in the Greek setting, where psycho-oncology infrastructure remains limited. The SBCS-GR helps clinicians make referral decisions, matching patients to the most appropriate interventions to their needs. This validation also supports the basis for evidence-based survivorship care in Greece. Researchers now have a psychometrically and culturally appropriate tool for studying stress in Greek breast cancer patients but also for evaluating interventions designed to reduce specific types of breast cancer-related distress.\u003c/p\u003e \u003cp\u003eThe Greek version of the SBCS demonstrates robust psychometric properties and successfully replicates findings from Spanish and Chinese validations, establishing it as a reliable and valid measure of cancer-specific stress. The scale shows excellent internal consistency (α\u0026thinsp;=\u0026thinsp;.94), theoretically coherent factor structure, and meaningful associations with established measures of psychological distress. Despite a smaller sample than the original validations, our results closely mirror those from other cultural contexts, with remarkably similar factor loadings and internal consistency estimates. This cross-cultural convergence suggests the SBCS captures universal dimensions of the breast cancer experience while remaining sensitive to individual variation in stress experiences. The instrument fills a critical gap in Greek psycho-oncology assessment by providing the first validated, cancer-specific stress measure for this population. It offers clinicians and researchers a brief (5\u0026ndash;7 minute administration time), psychometrically sound tool for systematically identifying specific stressors that breast cancer patients experience across the disease continuum\u0026mdash;from diagnosis through treatment and into survivorship. This validation represents an important contribution to evidence-based assessment in Greek oncology settings and enables future research examining how cancer-specific stress relates to health outcomes, quality of life, and psychological adjustment in Greek breast cancer populations. Moreover, the availability of validated SBCS versions in Spanish, Chinese, and now Greek creates opportunities for meaningful cross-cultural research that can illuminate both universal and culture-specific aspects of cancer-related stress, ultimately informing more culturally responsive supportive care interventions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThis study was approved by the Research Ethics Committee of Panteion University (Reg. Num. 52/10-03-2025).\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research received no grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eK.C. wrote the main manuscript text, G. R: prepared the figures and E.K supervised. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e We thank Alma Zois (Panhellenic Association of Women with Breast Cancer) and the 2nd Breast Clinic of IASO Hospital for facilitating participant recruitment and all the women who participated in this study.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to ethical restrictions and participant confidentiality but are available from the corresponding author upon request and with appropriate ethical approval.\u003c/p\u003e \u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTorre LA, Siegel RL, Ward EM, Jemal A. Global cancer incidence and mortality rates and trends--An update. Cancer Epidemiol Biomarkers Prev. 2016;25(1):16-27. doi:10.1158/1055-9965.EPI-15-0578\u003c/li\u003e\n\u003cli\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229-263. doi:10.3322/caac.21834\u003c/li\u003e\n\u003cli\u003eNoman S, Shahar HK, Abdul Rahman H, Ismail S, Abdulwahid Al-Jaberi M, Azzani M. The effectiveness of educational interventions on breast cancer knowledge, awareness, and screening behavior: Systematic review and meta-analysis. Int J Environ Res Public Health. 2021;18(1):263. doi:10.3390/ijerph18010263\u003c/li\u003e\n\u003cli\u003eSelye H. The stress of life. Revised edition. New York: McGraw-Hill; 1978.\u003c/li\u003e\n\u003cli\u003eLazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer Publishing Company; 1984.\u003c/li\u003e\n\u003cli\u003eLu S, Wei F, Li G. The evolution of the concept of stress and the framework of the stress system. Cell Stress. 2021;5(6):76-85. doi:10.15698/cst2021.06.250\u003c/li\u003e\n\u003cli\u003eTsaras K, Papathanasiou IV, Mitsi D, Veneti A, Kelesi M, Zyga S, Fradelos EC. Assessment of depression and anxiety in breast cancer patients: Prevalence and associated factors. Asian Pac J Cancer Prev. 2018;19(6):1661-1669. doi:10.22034/APJCP.2018.19.6.1661\u003c/li\u003e\n\u003cli\u003eMystakidou K, Tsilika E, Parpa E, Katsouda E, Vlahos L. Psychological distress of patients with advanced cancer: Influence and contribution of pain severity and pain interference. Cancer Nurs. 2004;27(3):197-205. doi:10.1097/00002820-200405000-00004\u003c/li\u003e\n\u003cli\u003eLiu L, Wu Y, Cong W, Hu M, Li X, Zhou C. Experience of women with breast cancer undergoing chemotherapy: A systematic review of qualitative research. Qual Life Res. 2021;30(5):1249-1265. doi:10.1007/s11136-020-02754-5\u003c/li\u003e\n\u003cli\u003eBoing L, Pereira GS, Ara\u0026uacute;jo CDCR, Sperandio FF, Loch MDSG, Bergmann A, Borgatto AF, Guimar\u0026atilde;es ACA. Factors associated with depression symptoms in women after breast cancer. Rev Saude Publica. 2019;53:30. doi:10.11606/S1518-8787.2019053000786\u003c/li\u003e\n\u003cli\u003eParikh D, De Ieso P, Garvey G, Thachil T, Ramamoorthi R, Penniment M, Jayaraj R. Post-traumatic stress disorder and post-traumatic growth in breast cancer patients--A systematic review. Asian Pac J Cancer Prev. 2015;16(2):641-646. doi:10.7314/apjcp.2015.16.2.641\u003c/li\u003e\n\u003cli\u003eCooper K, Campbell F, Harnan S, Sutton A. Association between stress, depression or anxiety and cancer: Rapid review of reviews. Compr Psychoneuroendocrinol. 2023;16:100215. doi:10.1016/j.cpnec.2023.100215\u003c/li\u003e\n\u003cli\u003eKalaitzi C, Papadopoulos VP, Michas K, Vlasis K, Skandalakis P, Filippou D. Combined brief psychosexual intervention after mastectomy: Effects on sexuality, body image, and psychological well-being. J Surg Oncol. 2007;96(3):235-240. doi:10.1002/jso.20835\u003c/li\u003e\n\u003cli\u003eRomito F, Lagattolla F, Costanzo C, Giotta F, Mattioli V. Music therapy and emotional expression during chemotherapy: How do breast cancer patients feel? Eur J Integr Med. 2013;5(5):438-442. doi:10.1016/j.eujim.2013.04.001\u003c/li\u003e\n\u003cli\u003eZakowski SG, Ramati A, Morton C, Johnson P, Flanigan R. Written emotional disclosure buffers the effects of social constraints on distress among cancer patients. Health Psychol. 2004;23(6):555-563. doi:10.1037/0278-6133.23.6.555\u003c/li\u003e\n\u003cli\u003eBjelic-Radisic V, Dorfer M, Tamussino K, Greimel E. Patients\u0026apos; view of routine follow-up after breast cancer treatment. Wien Klin Wochenschr. 2017;129(21-22):810-815. doi:10.1007/s00508-017-1278-1\u003c/li\u003e\n\u003cli\u003eBeaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25(24):3186-3191. doi:10.1097/00007632-200012150-00014\u003c/li\u003e\n\u003cli\u003eMehnert A, Berg P, Henrich G, Herschbach P. Fear of cancer progression and cancer-related intrusive cognitions in breast cancer survivors. Psychooncology. 2009;18(12):1273-1280. doi:10.1002/pon.1481\u003c/li\u003e\n\u003cli\u003eLee TY, Hsing SC, Li CC. An improved stress-scale specifically designed to measure stress of women with newly diagnosed breast cancer. Int J Environ Res Public Health. 2021;18(5):2346. doi:10.3390/ijerph18052346\u003c/li\u003e\n\u003cli\u003eCharalampopoulou M, Syrigos K, Filopoulos E, Megalooikonomou V, Vlachakis D, Chrousos G, Darviri C. Reliability and validity of the Newly Diagnosed Breast Cancer Stress Scale in the Greek population. J Mol Biochem. 2020;9:5-12.\u003c/li\u003e\n\u003cli\u003eMiceli J, Geller D, Tsung A, Hecht CL, Wang Y, Pathak R, Cheng H, Marsh W, Antoni M, Penedo F, Burke L, Ell K, Shen S, Steel J. Illness perceptions and perceived stress in patients with advanced gastrointestinal cancer. Psychooncology. 2019;28(7):1513-1519. doi:10.1002/pon.5108\u003c/li\u003e\n\u003cli\u003eShalchi Oghli S, Sadeghi R, Omranipour R, Rahimi Foroushani A, Ashoorkhani M, Tedadi Y. Comparison of the effect of mindfulness-based stress reduction therapy and usual care on quality of life in women with breast cancer. Med J Islam Repub Iran. 2024;38:16. doi:10.47176/mjiri.38.16\u003c/li\u003e\n\u003cli\u003eKatsarou A, Panagiotakos D, Zafeiropoulou A, Vryonis M, Skoularigis I, Tryposkiadis F, Papageorgiou C. Validation of a Greek version of PSS-14: A global measure of perceived stress. Cent Eur J Public Health. 2012;20(2):104-109. doi:10.21101/cejph.a3698\u003c/li\u003e\n\u003cli\u003eAndreou E, Alexopoulos EC, Lionis C, Varvogli L, Gnardellis C, Chrousos GP, Darviri C. Perceived Stress Scale: Reliability and validity study in Greece. Int J Environ Res Public Health. 2011;8(8):3287-3298. doi:10.3390/ijerph8083287\u003c/li\u003e\n\u003cli\u003eLiakos A, Giannitsi S. The reliability and validity of Spielberger\u0026apos;s modified Greek anxiety scale. Encephalos. 1984;21:71-76.\u003c/li\u003e\n\u003cli\u003eAnagnostopoulou T, Kioseoglou G. Spielberger\u0026apos;s state-trait anger expression inventory. In: Stalikas A, Triliva S, Roussi P, editors. Psychometric tools in Greece. Greek Letters; 2002. p. 285-286.\u003c/li\u003e\n\u003cli\u003eCerezo MV, Soria-Reyes LM, Pajares B, G\u0026oacute;mez-Mill\u0026aacute;n J, Blanca MJ. Development and psychometric properties of the Stressors in Breast Cancer Scale. Front Psychol. 2023;14:1102169. doi:10.3389/fpsyg.2023.1102169\u003c/li\u003e\n\u003cli\u003eHu W, Bao J, Yang X, Chen L, Zhu L, Wang Y, Teng Y, Sun Q. Psychometric evaluation of the Chinese version of the Stressors in Breast Cancer Scale: A translation and validation study. BMC Public Health. 2024;24:425. doi:10.1186/s12889-024-18000-3\u003c/li\u003e\n\u003cli\u003eCohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396. doi:10.2307/2136404\u003c/li\u003e\n\u003cli\u003eRosseel Y. lavaan: An R package for structural equation modeling. J Stat Softw. 2012;48(2):1-36. doi:10.18637/jss.v048.i02\u003c/li\u003e\n\u003cli\u003eWorthington RL, Whittaker TA. Scale development research: A content analysis and recommendations for best practices. Couns Psychol. 2006;34(6):806-838. doi:10.1177/0011000006288127\u003c/li\u003e\n\u003cli\u003eViladrich C, Angulo-Brunet A, Doval E. A journey around alpha and omega to estimate internal consistency reliability. An Psicol. 2017;33(3):755-782. doi:10.6018/analesps.33.3.268401\u003c/li\u003e\n\u003cli\u003eHu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6(1):1-55. doi:10.1080/10705519909540118\u003c/li\u003e\n\u003cli\u003eFornell C, Larcker DF. Evaluating structural equation models with unobservable variables and measurement error. J Mark Res. 1981;18(1):39-50. doi:10.2307/3151312\u003c/li\u003e\n\u003cli\u003eCohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.\u003c/li\u003e\n\u003cli\u003eKenny DA, McCoach DB. Effect of the number of variables on measures of fit in structural equation modeling. Struct Equ Modeling. 2003;10(3):333-351. doi:10.1207/S15328007SEM1003_1\u003c/li\u003e\n\u003cli\u003eMarsh HW, Hau KT, Wen Z. In search of golden rules: Comment on hypothesis-testing approaches to setting cutoff values for fit indexes and dangers in overgeneralizing Hu and Bentler\u0026apos;s (1999) findings. Struct Equ Modeling. 2004;11(3):320-341. doi:10.1207/s15328007sem1103_2\u003c/li\u003e\n\u003cli\u003eEuropean Observatory on Health Systems and Policies. Health systems in transition: Greece health system review. World Health Organization Regional Office for Europe; 2017. Vol. 19, No. 5.\u003c/li\u003e\n\u003cli\u003eMystakidou K, Parpa E, Tsilika E, Galanos A, Vlahos L. Cancer information disclosure in different cultural contexts. Support Care Cancer. 2007;15(3):235-240. doi:10.1007/s00520-006-0115-x\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Psychometric validation, Breast cancer, Stress assessment, Psycho-oncology, Patient-reported outcomes","lastPublishedDoi":"10.21203/rs.3.rs-9429181/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9429181/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eA breast cancer diagnosis causes significant psychological stress throughout the disease trajectory. While generic stress measures exist in Greek, validated cancer-specific stress assessment instruments are lacking. The Stressors in Breast Cancer Scale (SBCS) is a 24-item instrument assessing five stress domains: appearance/sexuality, health/daily life, interpersonal relationships, healthcare system and future worries. Given this gap in Southern European populations, this study evaluated the psychometric properties of a Greek translation of the SBCS.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional design was employed with a sample of 216 Greek women diagnosed with breast cancer. The scale's internal structure was examined through Exploratory and Confirmatory Factor Analysis (EFA, CFA). Internal consistency was assessed using Cronbach\u0026rsquo;s alpha and McDonald\u0026rsquo;s omega coefficients. Convergent validity was assessed through correlations with perceived stress and anxiety; discriminant validity was evaluated via comparison of AVE square roots with inter-factor correlations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe original five-factor structure was supported, demonstrating acceptable model fit (CFI = .89, RMSEA = .08). Internal consistency was high (α\u0026thinsp;=\u0026thinsp;.94). The SBCS-GR showed strong positive correlations with perceived stress and anxiety.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThese findings provide evidence supporting the structural validity and reliability of the SBCS-GR. The instrument may serve as a clinically relevant tool for identifying multidimensional stressors in breast cancer patients in Greece.\u003c/p\u003e","manuscriptTitle":"Psychometric validation of the Stressors in Breast Cancer Scale in Greece: Evidence for a five- factor structure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 05:08:45","doi":"10.21203/rs.3.rs-9429181/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-10T16:49:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15902780570124730140425328902094014189","date":"2026-04-28T07:27:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-27T15:42:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-18T06:27:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-17T01:37:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-17T01:37:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2026-04-15T15:24:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"46b328af-c1f2-4fbb-94d6-38fd0b42a354","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-10T16:49:27+00:00","index":59,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T05:08:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 05:08:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9429181","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9429181","identity":"rs-9429181","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}