INTRODUCTION
Thyroid cancer is the most common endocrine malignancy worldwide [1], with approximately 460,000 new cases reported in China in 2024 (according to the China Cancer Statistics Report), accounting for 9.6% of all newly diagnosed cancers. Compared to males, the incidence rate of thyroid cancer among females is nearly three times higher [2]. Thyroid cancer has also demonstrated a notable trend toward a younger age of onset both locally and abroad, with steadily increasing incidence rates [3,4]. Although thyroid cancer generally has a favorable prognosis, the increasing incidence and younger onset have shifted more attention toward long-term psychosocial outcomes. At present, surgical resection remains the primary treatment option for thyroid cancer in clinical practice, including conventional open thyroidectomy and endoscopic thyroidectomy (ET) [5]. Although ET has better cosmetic outcomes owing to its minimally invasive approach and concealed scar, it has not been extensively adopted in clinical practice because of the reliance on sophisticated equipment, high learning curve requirements for surgeons, and relatively high costs [6]. Therefore, traditional open surgery remains the final choice for some patients, resulting in an inevitable formation of a visible scar on the neck. Visible anterior-neck scars can lead to psychological concerns related to appearance.
Existing studies on stigma in thyroid cancer patients are relatively scarce compared with other cancers such as breast or oral cancer [7]. For many survivors, visible scars in the neck area are closely linked to personal appearance and social identity, leading to concerns about self-image and a tendency to avoid social situations. In East Asian populations, genetic and physiological factors heighten the risk of hypertrophic scarring, further exacerbating appearance-related anxiety [6]. Clinical surveys indicate that patients with thyroid cancer often experience self-perceived discrimination, including disease stigma, self-deprecation, and social avoidance. These feelings are frequently linked to appearance and functional issues resulting from postoperative manifestations, such as neck wounds [8]. A qualitative study on young Chinese thyroid cancer patients who underwent open surgery found that neck scars contribute to low self-esteem, social avoidance, employment restrictions, and reduced social participation. These psychological effects suggest that the stigma associated with illness in postoperative thyroid cancer patients is more widespread than previously believed, potentially leading to lasting impacts on self-image, social functioning, and treatment adherence. Research specifically addressing the prevalence, manifestations, and causes of discrimination among thyroid cancer survivors remains relatively limited compared to studies on breast cancer and head and neck cancer. This indicates a significant gap in current psycho-oncology research. The concept of disease stigma was first reported by Sociologist Goffman [9] in 1963. Illness stigma refers to the sense of shame that a person experiences due to their own health condition. In addition to external prejudice-based beliefs, stigma could also result from an internalized negative self-revelatory devaluation of the patients themselves; hence, it has been categorized into three dimensions: perceived, experienced, and internalized stigma [10].
In examining illness-induced psychological distress, traditional research has mostly focused on its detrimental outcomes and symptom-targeting interventions. In this regard, it is noteworthy that the recent emergence of positive psychology has yielded novel concepts that could be integrated into nursing clinical practice. Contrary to traditional methods, which focus on negative emotions, post-traumatic growth (PTG) interprets positive psychological alterations that individuals might experience after dealing with traumatic experiences in life [11]. Furthermore, according to Tedeschi and Calhoun’s PTG model [12], positive psychological change arises from individuals’ cognitive and emotional processing of highly challenging life events. This process involves reconstructing core beliefs, making meaning of experiences, and fostering an enhanced appreciation of life, all of which promote adaptive coping and improved interpersonal functioning. According to this model, PTG may act as a cognitive-emotional mechanism that counteracts negative self-cognition and alleviates disease-related stigma. For patients with thyroid cancer, the visible scars, anxiety about recurrence, and disruptions in their roles after surgery can serve as catalysts for personal growth. However, the role of PTG in altering patients’ perceptions of stigma has not been thoroughly examined.
Moreover, the psychological processes underlying PTG and stigma are complex, dynamic, and largely subjective. While quantitative research can identify associations, it cannot fully capture the lived experiences, meaning-making processes, and cognitive mechanisms that connect PTG with stigma reduction. On the other hand, qualitative inquiry alone cannot provide generalizable evidence. Therefore, a mixed-methods approach is particularly appropriate for this topic, allowing for both statistical analysis and an in-depth exploration of how survivors interpret and reconstruct their postoperative experiences.
To address these gaps, this study employed an explanatory sequential mixed-methods design. A quantitative phase was first carried out to quantify the levels of stigma and PTG and to explore their association after controlling for demographic and clinical covariates. Subsequently, qualitative interviews were carried out to explore the subjective psychological processes through which PTG may be related to patients’ experiences of stigma. Collectively, these findings will reveal the pathway linking PTG with stigma and to provide theoretical and empirical foundations for tailored nursing interventions that promote psychological recovery, reduce stigma, and foster long-term psychosocial adaptation among postoperative thyroid cancer survivors.
METHODS
Study subjects
An explanatory sequential mixed-methods design was adopted. First, quantitative analysis was used to determine the statistical association between PTG and stigma. Subsequently, qualitative research was performed to investigate the potential cognitive and emotional processes. This design enabled a comprehensive understanding of not only “whether” PTG is associated with stigma, but also “how and why” patients achieve positive psychological transformation following thyroidectomy. The protocol of this study was approved by the Medical Ethics Committee of Hunan Tumor Hospital (Rapid Review for Research 2022 [109]), and adhered to strict adherence to ethical standards in clinical research. All participants provided written informed consent prior to enrollment.
Quantitative phase
This phase of the study involved 184 thyroid cancer patients recruited through convenience sampling from the Department of Head and Neck Surgery at a tertiary hospital in Hunan Province between March 2023 and December 2024.
The inclusion criteria were: 1) patients pathologically diagnosed with thyroid cancer [13] who underwent thyroidectomy; 2) patients aged ≥18 years; 3) patients with basic reading and writing skills; and 4) patients who voluntarily agreed to participate in the survey.
The exclusion criteria were: 1) patients with a history of psychiatric disorders or severe diseases of the heart, brain, kidneys, or other major organs; 2) patients with communication challenges; 3) patients with recurrent thyroid cancer postoperatively; and 4) patients with other concurrent malignancies.
Qualitative phase
In this phase, participants were selected from the outpatients returning for follow-up visits between March and May 2025 through purposive sampling. Specifically, patients with relatively high levels of stigma (Social Impact Scale [SIS] score ≥49) in the quantitative phase—based on the principle of maximum variation—were included. The final sample size was determined through data saturation, resulting in 12 participants (labeled P1 to P12).
The inclusion criteria were: 1) patients in the quantitative phase with a moderate or higher level of stigma based on the SIS score during the initial questionnaire survey; 2) patients with a postoperative period ranging from 3 to 12 months [14,15], and currently undergoing outpatient follow-up; 3) patients willing to participate in the interview and signed an informed consent form; and 4) patients with complete clinical data.
The exclusion criteria were: 1) patients who voluntarily withdrew or discontinued from the study due to other reasons during the interview process and 2) patients with cognitive impairments or communication challenges during the interview.
Research tools
Quantitative phase
General information questionnaire: participants’ basic information was collected using a self-administered general information questionnaire, including sex, age, residence, educational background, marital status, family support, surgical method, family cancer history, monthly income, and living conditions.
SIS
This tool was developed by Fife and Wright [16] in 2000 and translated into Chinese by Pan et al. [17]. The scale’s Cronbach’s alpha coefficient in this study was 0.96, indicating high internal consistency. The scale comprises four dimensions (with a total of 24 entries), including Social Exclusion (9 items), Internalized Shame (5 items), Economic Discrimination (3 items), and Social Isolation (7 items). The items are graded using a 4-point Likert scale for responses, with individual scores ranging from 1 (strongly disagree) to 4 (strongly agree) and overall scores ranging between 24 and 96. Higher overall scores indicate higher levels of stigma. Stigma severity was categorized into three levels: mild (<49), moderate (49-72), and severe (>72).
Post-Traumatic Growth Inventory
This tool, originally developed by Tedeschi and Calhoun in 1996 [18], measures the level of positive psychological change an individual experiences following a traumatic event. Herein, we used a Chinese-adapted version of the scale [19], comprising 21 items divided into five dimensions: Personal Strengths (4 items), New Possibilities (5 items), Appreciation of Life (3 items), Relating to Others (7 items), and Spiritual Changes (2 items). Each item was graded using a score ranging between 0 and 5 yielding a total possible score of between 0 and 105. Higher scores indicated higher levels of PTG. The original measure had an overall consistency of 0.90, with 0.67-0.85 reported for individual dimensions. The Cronbach’s alpha coefficient for the Post-Traumatic Growth Inventory (PTGI) tool in this study was 0.91, reflecting a very strong reliability.
Qualitative interview guide
To ensure comprehensiveness, the interview guide was reviewed by two psycho-oncology experts and was pilot-tested with two thyroid-cancer survivors. This process confirmed that the questions elicited rich and relevant psychological content.
The final version of the interview guide included the following six questions:
1) What was your attitude like before & after your thyroid cancer diagnosis?
2) What changes, if any, have you experienced in your state of mind before and after surgery?
3) When you are feeling bad, how do you process or manage your psychological problems?
4) How do you believe you have changed in yourself since your illness?
5) Have you noticed any changes in the way other people treat you since your diagnosis?
6) From whom have you received the most support and/or care since you were diagnosed?
(Although the interview questions did not explicitly mention terms like “stigma” or “post-traumatic growth,” the outline was grounded in the PTG model [12] and prior qualitative research on cancer-related stigma. It explored patients’ emotional responses to surgery, shifts in self-perception and body image, social interaction experiences, and processes of coping and meaning-making. These topics theoretically match both the formation of stigma and the dimensions of PTG.)
Data collection and quality control
Quantitative phase
The data collection process was conducted in strict accordance with the principles of anonymity and voluntary participation. Before the survey began, the research team explained the study’s purpose and other relevant procedures to all participants. The questionnaires were then distributed and completed under supervision to ensure data quality. All completed questionnaires were collected on-site. To ensure accuracy, two independent researchers double-entered the data into SPSS 25.0 software (IBM Corp.). Of the 200 questionnaires distributed, only 10 were excluded due to incomplete demographic or scale responses. Furthermore, six participants declined to participate; hence, only 184 valid questionnaires were ultimately collected (response rate=92% [184/200×100]).
Qualitative phase
After explaining the purpose, significance, and procedures of the qualitative study to participants, the researchers asked them to provide written informed consent. The interviews were conducted in a quiet, private, and comfortable office setting. All interviews were audio-recorded, albeit with participants’ permission. To ensure depth and relevance, the interviewer adjusted the order and phrasing of questions flexibly based on each participant’s situation. Within 24 hours of each interview, two researchers transcribed the audio recordings verbatim.
Statistical analysis
Quantitative analysis
All statistical analyses were performed using SPSS (version 25.0) software (IBM Corp.). Continuous variables were expressed as mean±standard deviation, with independent sample t-tests or one-way analysis of variance used to examine inter-group differences in stigma scores. Hierarchical regression was employed to assess the layered effects of demographic variables and PTG scores on stigma. Pearson correlation analysis was used to examine the stigma-PTG relationship. All tests were two-sided, and results with p<0.05 were considered statistically significant.
Qualitative analysis
Interview data were processed and coded using NVivo 14.0 (Lumivero) software, and analyzed using a descriptive phenomenological approach. Two researchers independently performed content analysis [20] to extract subthemes and overarching themes, and discrepancies were resolved through discussion among research team members until a consensus was reached.
RESULTS
Quantitative findings
Stigma and PTG levels in postoperative thyroid cancer patients
The 184 participants had a mean stigma score of 61.62±13.33. The four subdimensions were ranked based on mean scores from highest to lowest as follows: Social Exclusion (21.91±6.05), Social Isolation (18.34±3.96), Internalized Shame (13.34±2.77), and Economic Discrimination (8.07±1.74). On the other hand, the mean PTG score was 60.54±14.78 and the highest to lowest dimension scores were ranked as follows: Relating to Others (18.72±6.16), New Possibilities (13.95±4.38), Personal Strength (11.85±3.51), Appreciation of Life (8.91±2.36), and Spiritual Changes (4.59±1.76) (Table 1).
Stigma scores based on patient characteristics
Univariate analysis revealed statistically significant differences in stigma scores across the sex, education level, surgical method, monthly income, and family support level subgroups (p<0.05) (Table 2). There were no significant differences in stigma scores among the subgroups of age, current address, marital status, family history of cancer, and condition (p>0.05) (Table 2).
Correlation between stigma and PTG
The Pearson correlation analysis indicated that the total score of stigma was significantly negatively correlated with the total score of PTG (r=-0.632, p<0.01). This negative correlation remained statistically significant in all other subdimensions (p<0.01), with correlation coefficients ranging from -0.431 to -0.702 (Table 3).
Association between PTG and stigma among postoperative thyroid cancer patients
The predictors of stigma scores were identified using hierarchical regression analysis. First, the key variables (including sex, education level, surgical method, monthly income, and family support) were identified from the single-variable analysis and were included as independent variables in the model. The results showed that sex (β’=0.268, p<0.01), education level (β’=-0.297, p<0.01), surgical method (β’=-0.177, p<0.01), and monthly income (β’=-0.147, p<0.05) were among the core predictors of the stigma score, but family was not a significant contributor (β’=0.091, p=0.155). This model was strongly correlated with the stigmatization score and explains 33.3% of the variance (R²=0.333, F=17.760, p<0.01). When the total PTG score was included, the results showed that PTG showed a strong negative association with stigma (β’=-0.495, p<0.01), and sex (β’=0.204, p<0.01) and surgical method (β’=-0.136, p<0.01) remained significant; monthly income and family support had no significant contribution (p>0.05). Notably, the total PTG score was integrated into the model, which accounted for an additional 21.7% of the variance in stigma scores (ΔR²=0.217, p<0.01; final model: R²=0.550, F=36.013, p<0.01) (Tables 4 and 5).
Qualitative findings
Participant characteristics
Only 12 patients were interviewed, designated as P1 to P12. Among them, 10 were females, with an age range of 23 to 61 years (40.33±12.40 years). The educational background was as follows: 2 with primary school education, 2 with secondary school education, 7 with university/college education, and 1 with master’s degree. Furthermore, the surgical methods showed that 8 underwent traditional open surgery and 4 chose transoral thyroidectomy. The total stigma scores ranged between 52 and 72 (64.75±5.61).
Interview themes
Reconstructing a positive mindset amid psychological struggles
Although the patients experienced marked emotional distress at the time of diagnosis and early treatment, many adopted more positive outlooks over time through cognitive reframing and emotional regulation.
Early-stage anxiety and emotional adjustment
P1: “When I was first told it was malignant, I was under a lot of pressure. But after hearing the doctor explain that thyroid cancer has a good prognosis, I gradually felt less burdened.” P2: “At diagnosis, I thought my world was falling apart. But after calming myself and hearing from the doctor that it’s curable, I managed to reduce my anxiety.” P9: “At first, they suspected lymphoma. I cried—I thought it was something incurable. But once I learned it was thyroid cancer and treatable, I felt much more at ease.”
Cognitive reframing and long-term adjustment
P4: “Before checkups, I feel nervous. I try to distract myself with TikTok or walking.” P7: “I’m mainly worried about recurrence now, but I figure, if it comes back, we’ll just deal with it again.” P9: “I now treat myself like a normal person, not a patient. That really helps.”
Reconstructing illness cognition through social support
Family support and hearing from peer experiences play a crucial role in empowering patients to cope with loneliness and regain a sense of control.
Emotional empowerment from family support
P3: “My family’s care after surgery helped me feel less alone.” P5: “Sometimes my mother’s anxiety about my health actually made me more stressed.” P7: “At first, I didn’t want surgery. I was afraid. But my family encouraged me, so I agreed.” P11: “I had a tough time recovering, but with support from my mom, sister, and husband, I got through it.”
Peer sharing and mutual support
P2: “My cousin had the same cancer and later had a baby while on levothyroxine. That reassured me.” P4: “Thyroid cancer is common among teachers. Knowing colleagues had it too made me less anxious.” P12: “I left the patient group chat because it kept reminding me I was ill, and that made me more anxious.”
Behavioral adaptation and self-identity reconstruction
Patients actively modified their lifestyles, managed their appearances, and redefined their social roles, ultimately gaining a sense of control and identity.
Lifestyle adaptation
P1: “I used to stay up all night working. Now I sleep much earlier because of this illness.” P6: “I quit smoking and drinking. I take my medication daily—just like treating hypertension or diabetes.” P9: “Taking the meds daily has become a habit, almost like taking supplements.”
Appearance management and social role reintegration
P2: “I wear a pearl necklace to cover my scar. I don’t want people to know I had cancer.” P9: “I use scar patches and wear high-collar clothes. I’d feel uncomfortable exposing the scar.” P11: “At first, I covered it with a scarf, but now I’ve just accepted it.” P12: “I chose transoral surgery to avoid scars, but I still remove the illness info from my health reports when sharing them.”
DISCUSSION
Stigma in postoperative thyroid cancer patients
In this study, the overall stigmatization score of postoperative thyroid cancer patients was 61.62±13.33, which fell within the medium-high range. This result, in conjunction with previous studies reporting the baseline level (55.61±12.21) [21], jointly indicates that thyroid cancer patients generally encounter significant stigmatization. Stigma experiences could be influenced or expressed differently depending on the type of cancer. For instance, oral cancer survivors could experience visible disfigurement, speech or eating issues, and psychological distress, potentially leading to feelings of inferiority and social isolation [22]. The survivors of thyroid cancer often experience persistent anxiety about their appearance due to neck scars, social gaze pressure, and challenges in reconstructing their identity. In this context, we identified several potential factors contributing to the increased levels of stigma among thyroid cancer patients who have undergone surgery. One significant factor is traditional open thyroidectomy, which typically results in visible neck scars after the procedure [23], remains the mainstay surgical intervention in China. Notably, East Asian patients (predominantly of Chinese origin) have a significantly higher risk of developing hypertrophic scars due to the combined effects of genetic and nutritional factors [6]. Second, concerns about cancer recurrence and uncertainty could exacerbate patients’ incidences of stigma [24]. Third, thyroid cancer often occurs in women, who are also more concerned about their appearance, making them particularly vulnerable to stigma [25]. Fourth, cancer patients are often discriminated, manifested as stereotyping, differential treatment-based exclusion, and systemic marginalization. This phenomenon is particularly prominent after diagnosis.26 These findings collectively highlight the need for healthcare workers to proactively assess stigma levels along with other psychological health parameters in postoperative thyroid cancer patients.
Association between PTG on stigma among postoperative thyroid cancer patients
Quantitative analysis revealed that higher PTG was significantly associated with lower stigma, and explained an additional 21.7% of the variance beyond demographic factors.
Moreover, qualitative results supported the above observations, showing three interconnected mechanisms: 1) cognitive restructuring and positive reinterpretation, 2) meaning reconstruction through social interaction, and 3) behavioral self-reintegration. Together, these findings indicate that PTG operates as a transformative cognitive-emotional process, enabling individuals to reinterpret illness-related experiences—thereby mitigating self-stigma and enhancing psychological adjustment. This pattern reflects the cognitive and emotional reconstruction central to the PTG model. This mechanism is consistent with the PTG framework proposed by Tedeschi and Calhoun [12], which conceptualizes growth as a positive transformation following trauma via the rebuilding of cognitive schemas, the discovery of new meanings, and the strengthening of social connections.
Data from empirical studies have provided further evidence for this theoretical perspective in oncology contexts.
For example, Özönder Ünal et al. [27] found that self-compassion and psychological flexibility were positively associated with PTG among cancer patients during the COVID-19 pandemic, highlighting self-compassion as an adaptive emotion-regulation mechanism fostering growth. Similarly, Liao et al. [28] demonstrated that psychological resilience and self-disclosure mediated the relationship between loneliness and PTG in gynecologic malignancy patients, underscoring meaning-making and social connection as crucial pathways to positive psychological outcomes. Building on this empirical foundation, thyroid cancer survivors with higher levels of PTG may engage in deep reflection, reconstruct personal meaning, and reframe their illness as an opportunity for psychological and interpersonal development. This process can help reduce perceived stigma. Through cognitive restructuring, individuals can transform threat-based self-schemas into growth-oriented identities, which in turn alleviates internalized shame and social withdrawal linked to illness-related stigma. An interesting finding is that family support was not a significant predictor of stigma (β’=0.091, p=0.155), contradicting the common assumption that social support benefits mental health. This may be explained by two key factors: first, the study only measured overall family support without distinguishing subtypes (e.g., emotional, instrumental support), and inappropriate support can increase psychological pressure rather than reduce stigma [29], consistent with patient feedback like “my mother’s anxiety stressed me more.” Second, Chinese cultural emphasis on “family harmony” and avoidance of “stigma-related discussions” often overlooks patients’ psychological needs (e.g., avoiding conversations about scars), weakening direct support effectiveness [30]. Taken together, these findings suggest that merely increasing the quantity of family support may not be sufficient to reduce stigma. Instead, psychosocial interventions should prioritize improving the quality of support—for example, promoting need-based emotional support, facilitating open communication about stigma-related concerns, and training family members to respond in ways that reduce pressure rather than amplify it. Future research should further clarify which specific types of family support are most effective and at what time points they exert the strongest influence, so as to better inform targeted stigma-reduction strategies for patients after thyroid cancer surgery.
Potential pathways linking PTG and stigma
Herein, we employed a qualitative approach as a complement to the quantitative analysis to further explore the mechanisms underlying the relationship between PTG and stigma. Thematic analysis identified three major themes from the interview data: “Reconstructing a Positive Mindset Amid Psychological Struggles,” “Rebuilding Illness Cognition Through Social Support,” and “Behavioral Adaptation and Self-Identity Reconstruction,” as the specific paths for patients to cope with stigma and achieve growth or progress across the psychological, social, and behavioral fronts, respectively.
Reconstructing a positive mindset amid psychological struggles
Most of the patients included in this study described how they had transitioned from an anxious, fearful state to a more stable emotional and positive state. At the onset, they were largely overwhelmed by stress and worry following the cancer diagnosis. However, they (gradually) re-established psychological balance through professional medical counseling, self-regulation techniques, and evidence-based interventions promoting positive thinking. These narratives reveal that PTG is not a passive result but an active, effortful process of adaptation that patients engage in over time. Patients described moments of reflection and meaning-making that led to a reinterpretation of their illness as a turning point in life. The PTG theory posits that when faced with a potentially life-threatening condition, an individual might experience cognitive restructuring through detailed information searching and supportive social reflection, which ultimately reduces some of the initial stress reaction [31]. Clinicians and other healthcare professionals should prioritize the identification and intervention of patients’ emotional responses at the time of diagnosis before proceeding with surgical considerations. Adopting informal education structures, clear purposeful discussions of “risk” and assumptions, and supportive social discourse could collectively help patients accurately determine their condition and address personal assumptive ways of thinking. Clinical professionals could also suggest formal self-regulation strategies (for example self-encouragement verbalization and mental distraction) for cognitive reframing to improve the patients’ personal mood development [32]. Moreover, a systematic structure to psychological intervention could significantly reduce anxiety and lay a foundation for developing PTG and long-term rehabilitation plans [33].
Reconstructing illness cognition through social support
Social support may play an important role in shaping thyroid cancer patients’ perceptions of their illness after surgery. Herein, consistent with Faraci’s research [34], we found that emotional support from family members markedly impacted the diminishing feelings of loneliness and helplessness, increasing the patients’ confidence to cope with the disease. Peer engagement was also documented as an additional source of support, and was particularly deemed valuable to postoperative patients who had chosen to enroll in peer support groups. Our findings align with those reported by Harkin et al. [35] in his previous study. We also found that the experiences of communicating and sharing with others can enhance patients’ understanding of the diagnosis of thyroid cancer, reducing the sense of isolation or fear caused by the diagnosis.
However, the burden of exposure to excessive negative information generated within support groups detrimentally affected some patients. It is noteworthy that assessing the nature of a patient’s support system could be key in involving family members to help make the patients’ experience more normal and opening communication pathways that might elicit an accurate understanding of the disease without any concealment [36]. In future, researchers should develop structured, professionally moderated peer engagement platforms that emphasize resilience-building and accurate disease interpretation, while minimizing the risk of emotional contagion. Meanwhile, potentially harmful negative information that could provoke anxious feelings about the patients’ illness should also be limited or inhibited [37].
Behavioral adaptation and self-identity reconstruction
The results findings further revealed that as thyroid cancer patients adjusted to their lives post-diagnosis and -surgery, adopting proactive measures to modify their lifestyle and appearance played a critical role in reconstructing their self-identity. Specifically, many patients altered their sleep routines, improved their diets, and engaged in intermittent exercises. These changes promoted their physical recovery and enhanced their sense of control over their health and overall quality of life [38]. These modifications also equipped the patients better to respond to physical changes in a healthier manner, thus reducing anxiety and depression [39].
Many patients also attempted to redefine their social lives by covering the surgical neck scars and improving their appearance. They covered or modified the scars, on the one hand, to look more natural, and on the other hand, to reduce the inferiority resulting from stereotyping issues [40]. Meanwhile, many patients choose to selectively share their experiences of the illness with others. On one hand, this can help them build a more positive self-image and better understand their medical condition. This sharing enables the patients to improve their sense of belonging and promotes their psychological recovery, enabling them to better return to a normal life [41].
These findings underscore the importance of supporting patients’ behavioral adaptations as an integral component of clinical care for thyroid cancer patients. Appropriate nursing interventions can improve sleep hygiene, nutrition, physical activity, and medication adherence while remaining attentive to their emotional responses to physical changes. Such behaviors will include scar care recommendations (e.g., silicone gel sheets or massage), managing appearance (e.g., scarves or makeup), and enhancing access to emotional support. Clinicians should aim to help patients accept and integrate bodily changes thereby improve identity reconstruction [41]. In future, nursing research is needed to explore the specific mechanism and path of health behavior adaptation and appearance recognition intervention, thus promote PTG and reduce stigma in patients with thyroid cancer after surgery, as well as formulate more refined and comprehensive rehabilitation support plans combined with individualized evaluation [42,43].
Limitations and implications
This study has several limitations. First, the cross-sectional design of the quantitative phase restricts causal inference. Although hierarchical regression analyses indicated that PTG was significantly associated with lower levels of stigma, the cross-sectional nature of the data means that the relationship should be interpreted as associational rather than causal. Therefore, longitudinal or experimental studies are warranted to clarify the temporal relationship between PTG and stigma. Second, the quantitative phase employed a convenience sampling strategy to recruit participants from a single tertiary hospital. While this approach facilitated efficient recruitment in a clinical setting, it may introduce selection bias, and the sample may not fully represent the broader population of thyroid cancer survivors. Consequently, the generalizability of the findings may be limited. Future studies are encouraged to adopt multicenter designs and probability-based sampling methods to improve representativeness and external validity. Third, the qualitative interviews included a relatively small sample, suggesting that future research should aim for more diverse participants to enhance understanding. Clinically, the integrated findings underscore PTG as a promising psychological target for nursing interventions. Psychosocial programs that promote cognitive reframing, foster balanced family communication, and encourage behavioral self-management may help reduce stigma and improve adaptation among thyroid cancer survivors.
Conclusion
In summary, this explanatory sequential mixed-methods study demonstrates that PTG may play a protective psychological role in relation to postoperative stigma among thyroid cancer survivors. Based on PTG theories, the findings indicate that positive cognitive reappraisal and meaning reconstruction are essential psychological mechanisms that help reduce stigma and facilitate psychosocial recovery.
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