Cancer stigma is a global public health concern, contributing to poor health and social inequality among survivors [1]. Stigma, which can be categorized as involving both public stigma and internalized stigma, is produced through complex societal processes [2]. The term “cancer” may automatically evoke fears of death (negative stereotypes or ignorance) or emotional discomfort (prejudice), which then may lead to discrimination toward cancer survivors. Survivors who are aware of this public stigma, in turn, may experience diminished self-esteem, intense self-blame, and shame [3], reflecting internalized stigma.

Public stigma undermines the cancer care continuum by reducing screening uptake, delaying diagnosis, and lowering treatment adherence, which can contribute to poor survival outcomes [1,4,5]. The literature further demonstrates that stigma negatively affects survivorship through impaired mental health [6-8], weakened social relationships [9], and reduced social participation [8,10]. Survivors of breast, cervical, prostate, and lung cancer are particularly vulnerable; the associations reported between these survivors and sexuality or risk-related behaviors (eg, smoking) may intensify both public and internalized stigma [3,7,9,11,12], further hinder timely access to care [4,8,13], and worsen quality of life (QoL) [3,14,15].

In Japan, however, policy interventions are not primarily aimed at reducing mortality through stigma mitigation. Instead, as articulated in the Fourth Basic Plan for Cancer Control [16], the national focus is on cancer survivorship through promoting coexistence with cancer by reducing stigma, enhancing public understanding, and fostering a supportive environment for survivors. This approach emphasizes citizen engagement and social inclusion to improve survivors’ QoL and to remove stigma-related barriers to social participation.

To reduce stigma, multitheory and multilevel interventions are recommended [13,17-20]. These approaches are grounded in the socioecological model, which emphasizes the dynamic interactions between intrapersonal factors and broader environmental contexts, such as interpersonal relationships, organizational structures, community settings, and policy frameworks [21]. Most illness-related stigma reduction programs focus on HIV/AIDS, leprosy, tuberculosis, mental illness or substance use disorders, and epilepsy [17-19,22], with limited numbers of cancer-specific intervention programs [1,23]. In Japan, 1 intervention dealing with romantic relationships among Japanese youngsters has been reported [24]. Most interventions rely on education and/or intergroup contact [17-19,21,24]. Sustaining intergroup contact poses challenges due to infectious risks (eg, COVID-19) and the burden on patients with cancer. Thus, interventions that minimize in-person contact while maintaining efficacy are needed.

Intervention content and delivery must also reflect relationships that survivors have (eg, with friends, colleagues, employers, teachers, caregivers, neighbors, and even those with no prior connection), survivors’ cancer types, and available provider resources (eg, human and infrastructure). However, developing multiple intervention versions for each context is impractical [25]. Instead, adapting core components may be a more feasible approach. We focused on friendships, which are vital to survivors’ well-being across the lifespan [26,27]. According to stigma research, engaging with hypothetical friends has been shown to help reduce psychological distance and foster empathetic understanding of an individual’s experience of stigma [28].

We developed a 5-week web-based experiential learning program named “Friend Supporter” that was designed for the adult public with no history of cancer diagnosis (hereafter, the public). In this program, experiential learning is defined as a method that allows the program participants to learn the contents of the program and deepen their understanding of practical conduct through simulation. The program centers on a hypothetical scenario: “What if your friend were diagnosed with cancer?” This framing enables broad participation regardless of prior connection to cancer survivors as friends. The primary outcome of the program was helping intentions, assessed immediately after program completion. In addition, the program was designed to foster long-term outcomes, including supportive interactions with adult cancer survivors, increased support provision, and stigma reduction.

The intervention was conceptually designed for broad applicability across cancer types in adulthood, with a theoretical foundation that addressed common relational challenges and support needs identified in diverse contexts [29]. Through text-based role-play, program participants practice empathetic listening and supportive responses across diverse scenarios. These scenarios vary by cancer type, age, gender, occupation, disclosure context, and conversational content. These varied scenarios are intended to help participants adapt to different contexts. By applying core interpersonal skills learned through the program, they can respond more effectively across various situations. The program is grounded in the socioecological model and primarily focuses on intrapersonal and interpersonal levels, but with further potential effects at organizational and community levels.

This paper aimed to illustrate the developmental processes of the 5-week web-based experiential learning program “Friend Supporter,” using the first 4 steps of the intervention mapping (IM) approach [30].

Ethical approval for the survey conducted among the public was obtained from the institutional research board of the National Cancer Center (2017‐378). Ethical approval for the survey among cancer survivors was obtained separately from the institutional research board of the National Cancer Center (2017‐134). For the 2 surveys, appropriate electronic informed consent was obtained from all participants. The surveys were anonymous. Participants in the public survey received a 2,000-yen gift voucher (approximately 17 USD at the time of study).Ethical approval for pilot testing was obtained from the institutional research board of the National Cancer Center (2021‐020). Electronic informed consent was obtained from all participants. Participants in the interviews received a 2,000-yen QUO card (a prepaid purchasing card), which was approximately 15 USD. No personally identifiable information, including initials, was included in the transcripts and the published results. All procedures were conducted in accordance with the ethical standards of the institutional research board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

The relevant literature shows that some members of the public have negative reactions toward cancer survivors due to beliefs about cancer (eg, “cancer equals death” and “incurable disease” [37]), lack of familiarity with survivors, and perceptions of the risk factors [37-39]. These interactions can adversely affect survivors’ self-concepts, cognitive reappraisals, social disclosure [35,36], help-seeking behaviors (eg, less medical use), treatment adherence [39], mental health status [39], and QoL [36]. Psychological theories such as stigma attribution theory [40,41] and empathetic coping theory [42] have been used to elaborate on the links between the general public’s attitudes and the impact of such attitudes on cancer survivors. The findings underscore the need to address cancer stigma across the cancer experience, including coexistence, early detection, and clinical care. Figure 1 illustrates the relationship among health problems, QoL, and associated factors. The multidisciplinary planning team agreed to this logic model of the problem.

The logic model of change was structured around three key components: performance objectives, change objectives, and personal determinants. This stepwise structure enabled a systematic evaluation of how targeted changes in personal determinants may lead to behavioral shifts, ultimately contributing to a more supportive environment for cancer survivors. While improved QoL of cancer survivors was the ultimate goal, this was not directly measured in this model.

To clarify the logic of change, the primary outcome was defined as strengthening the public’s intention to support hypothetical friends with cancer, representing the short-term learning effect of the program. This proximal change was considered a key indicator of immediate program success. To achieve the primary outcome, the intervention targeted intrapersonal mediators of change, such as increased knowledge about cancer and cancer survivors and greater self-efficacy, as well as interpersonal skills such as empathetic coping skills. Change objectives for each performance objective were presented together with personal determinants (knowledge, skills, self-efficacy, and attitudes) in a matrix; for example, regarding change objectives aimed at reducing stereotypes and prejudice about cancer and cancer survivors, personal determinants associated with knowledge focused on “increasing accurate knowledge of cancer and cancer survivors” (Multimedia Appendix 1). These short-term shifts were theorized to contribute to the long-term goals outlined in the three performance objectives and were expected to emerge over a span of 2 to 3 years.

This study is the first to apply the IM approach to develop a web-based experiential learning program aimed at reducing cancer stigma among the public.

We set out and described the first four steps of the IM approach [30]. While adapting existing evidence-based intervention programs can be more efficient than creating new ones, there remains a notable lack of programs aiming to reduce cancer stigma [1,23]. Therefore, it was considered worthwhile to undertake and report on a step-by-step developmental process that integrates empirical findings, behavioral change theories, and practical input. The incorporation of expert panel input and user feedback through a think-aloud approach significantly enhanced content refinement, as well as the relevance and feasibility of the final product.

The intervention logic model allowed for the development of the hypothesis that the primary goal of this proposed intervention program would be achieved, namely, to increase helping intentions toward hypothetical friends with cancer. We set up multiple mediators: increasing knowledge, empathetic skills, and self-efficacy. Individuals with heightened helping intentions are more likely to respond supportively when someone discloses a cancer diagnosis. Over time, such attitudinal changes may contribute to the three specified long-term outcomes: improved interpersonal responsiveness, increased support provision, and reduced stigma. If supportive behaviors become widespread across interpersonal, organizational, and community levels, the subsequent effects are more likely to foster a culture of inclusion, one that accepts cancer without prejudice and reduces discrimination against cancer survivors. While QoL was not explicitly defined as a direct outcome in the logic model, it serves as a foundational construct that underpins the broader objectives of the program. By fostering supportive environments and reducing stigma, the program is expected to indirectly contribute to enhancing the QoL of cancer survivors.

Prior studies have shown that public stigma contributes to internalized stigma among cancer survivors [6-14,59]. This dynamic aligns with the socio-ecological framework, which recognizes the interplay between societal attitudes and individual experiences. Whereas most digital interventions using IM have focused on intrapersonal factors to support individuals with cancer [32,33], our program uniquely targets the public, situated in the outer layer of the socio-ecological model, to promote broader cultural and relational change. Similar logic has been applied in intervention development targeting parental behavior, with the intention of indirectly influencing children’s physical activity levels by modifying relational dynamics [60].

Previous stigma reduction efforts have largely emphasized knowledge acquisition, including exposure to patient narratives [18-22,24]. However, social cognitive theory [61] suggests that knowledge alone may be insufficient to drive behavioral change; attitudes toward behavioral intentions are also essential components in predicting supportive actions toward individuals with cancer. Our experiential learning integrates empathy training together with cancer-related knowledge to foster emotional and cognitive empathy, and to enhance self-efficacy and helping intentions toward cancer survivors.

Unlike prior stigma studies that focused on specific cancer types [4,6,8,9,11-13,15,59], our program addresses stigma toward cancer survivors more broadly and is applicable to any kind of relationship. Centering on relational challenges and support needs common to diverse cancer contexts [29], the materials were intentionally designed for wide applicability. In addition to fostering transferable interpersonal skills, the program also equips participants with foundational knowledge about cancer, treatment processes, and the social lives of patients, namely survivorship. The program’s modular design allows for the inclusion of supplementary materials tailored to specific cancer types, enhancing its adaptability across diverse contexts.

This project demonstrates several key strengths in relation to the development of a web-based experiential learning intervention for cancer stigma reduction. First, the use of the IM framework enabled a systematic integration of theory, empirical evidence, and practical input. A multidisciplinary planning team guided the process through structured consensus-building, ensuring that diverse perspectives were reflected and that certain professional opinions were not overly influential. Second, the logic model helped identify and target essential mediators—knowledge, skills, and self-efficacy—within the program materials. The public survey data further informed the content and delivery preferences, aligning the intervention with the needs of both the public and cancer survivors. Appropriate reflection on the public’s needs, together with cancer survivors’ needs, may help motivate participation, implementation, and dissemination [43]. Third, the inclusion of communication-focused components and empathy training was undertaken in response to stigma-related challenges identified in prior research [56]. Various techniques, such as modeling, feedback, and first-person narratives [47], were incorporated to enhance self-efficacy and promote prosocial attitudes. The clinical psychologists’ written feedback on worksheets may provide further assurance and facilitate prosocial attitudes. Finally, expert reviews and end user feedback contributed to the credibility, feasibility, and relevance of the program, increasing the likelihood of achieving its performance objectives and supporting future implementation.

Regarding limitations, the investigation of the research on cancer stigma was limited to creating a logic model of the problem. However, recent findings suggest that public stigma may intersect with structural factors such as education and employment [10,62-64]. Future studies should address structural dimensions of stigma, which were not explicitly targeted in the current program. Further, we used the end user approach. However, while we did not invite cancer survivors into the expert panel, we compensated for this limitation by using the findings of the needs survey among cancer survivors. Finally, we did not establish a specific performance objective or change objectives for the environmental impact. In the future, appropriate change methods and practical applications should be identified and combined.

We plan to assess the effectiveness of this web-based intervention program, “Friend Support,” quantitatively, using randomized clinical trials among the public. If its effectiveness is confirmed, implementation studies could be performed in the future using steps 5 and 6 of the IM approach. To facilitate dissemination, intervention packages, including materials for users, a practical guide for program providers, and feedback training workshops for researchers and clinicians, have been prepared. A developed practical guide would be helpful for staff training, not only in terms of providing feedback on worksheets but also for understanding how to deliver the intervention program effectively.

For future implementation, collaboration with schools, companies, and community-based organizations, such as nongovernmental organizations or civil groups, could support localization and sustainable delivery. While the current program is framed around the role of a friend, extending this application to other social roles, such as workplace colleagues or teachers, may enhance its relevance. Core components of the program, particularly those related to interpersonal empathy and supportive communication, can be retained while adapting delivery methods to suit different contexts. For instance, incorporating reflective exercises that prompt program participants to consider how they might respond if a coworker or student were diagnosed with cancer could deepen empathy and foster supportive engagement in professional or institutional settings. These adaptations may also help address stigma in environments where social dynamics are shaped by hierarchical or role-based interactions.

The intervention has the potential to serve as a long-term resource for the public, promoting supportive attitudes and behaviors toward cancer survivors. Although the program was developed in response to Japan’s legal emphasis on stigma reduction in cancer survivorship, future research may explore whether stigma reduction can also encourage preventive behaviors, such as cancer screening and health care-seeking attitudes and behaviors [4,5,8,13].

IM is a useful framework for integrating theory, evidence, and practical inputs to develop a web-based experiential learning intervention program designed for the public to reduce cancer stigma. A qualitative pilot test demonstrated the program’s feasibility, but further evaluation involving the public is required before implementation can be considered. We hope this tutorial paper will help researchers and educators systematically develop similar web-based experiential learning interventions, particularly those using simulation to address stigma and promote an inclusive and supportive community.