Depressive Symptoms Mediate the Associations of Stigma with Medication Adherence and Quality of Life in Tuberculosis Patients in China

The relationship between stigma and quality of life in hospitalized middle-aged and elderly patients with chronic diseases: the mediating role of depression and the moderating role of psychological resilience

Objective

Patients with chronic diseases may have some psychological problems due to their own or surrounding environmental factors, which can adversely affect the patient's illness and life. Given that the number of chronically ill patients in China is currently increasing every year, more research is needed to determine the best ways to manage changes in psychological status and psychological stress responses in chronically ill patients. The researchers constructed a mediated moderation model to explore the impact of stigma on the quality of life of chronically ill patients, as well as the mediating role of depression and the moderating role of psychological resilience.

Methods

A stratified sampling method was used to select 363 middle-aged and old-aged patients with chronic diseases aged 45 years and older from the Affiliated Hospital of Zhejiang University for the study. Data were collected from patients with chronic diseases such as cardiac, respiratory, renal, and other chronic diseases using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), the Stigma Scale for Patients with Chronic Diseases (SSCI), the Patient Health Questionaire-9 (PHQ-9), the Quality of Life Inventory (SF-12), and the Conner-Davidson Resilience Scale (CD-RISC) were collected from patients with cardiac, respiratory, renal, and other chronic diseases. A descriptive analysis was used to describe the sample. Linear regression was used to evaluate the relationship between the variables. Mediation and moderation analyses were used to explore the mediating role of depression and the moderating role of psychological resilience.

Results

There was a moderate negative correlation between stigma and quality of life (r = -0.378, P < 0.01). There was a moderate negative correlation between depression and quality of life (r = -0.497, P < 0.01). There was a moderately positive correlation between psychological resilience and quality of life (r = 0.382, P < 0.01). There was a moderate negative correlation between psychological resilience and depression (r = -0.348, P < 0.01). There was a weak negative correlation between psychological resilience and stigma (r = -0.166, P < 0.01). There was a strong positive correlation between stigma and depression (r = 0.607, P < 0.01) The mediation study showed that stigma was a significant predictor of quality of life and that stigma and quality of life were mediated to some extent by depression, with the mediating effect accounting for 67.55% of the total effect. The direct path from stigma to depression is moderated by psychological resilience (β = -0.0018, P < 0.01).

Conclusions

Depression mediates the relationship between stigma and quality of life, while psychological elasticity plays a moderating role between stigma and depression, and when the level of psychological elasticity increases, the more significant the role of stigma on depression. As a physiologically and psychologically vulnerable group, patients with chronic diseases' overall quality of life and mental health should be taken more seriously, and clinical workers should pay timely attention to the psychological and mental conditions of patients with chronic diseases and provide timely and appropriate interventions and therapeutic measures. The relevant results of this study also provide a new perspective for clinical work on psychological intervention for patients with chronic diseases.

Effects of Social Support on Medication Adherence Among Patients with Schizophrenia: Serial Multiple Mediation Model

Purpose

This study aims to explore the serial mediating effect of stigma and depression on the association between social support and medication adherence.

Patients and Methods

A cross-sectional survey was undertaken in the Changning District of Shanghai using a five-part questionnaire from August to December 2023. A convenient sampling method was employed, and 35 patients with schizophrenia were invited from each of the 9 streets in Changning District to participate in the survey, resulting in a total of 305 valid questionnaires collected. The questionnaire measured social support, stigma, depression, medication adherence, and demographic characteristics. Data analysis involved descriptive statistics, independent samples t-tests, ANOVA, Pearson correlation analysis, and the bootstrap method.

Results

There was a direct and significantly positive association between social support and medication adherence (β = 0.69, p < 0.001). Moreover, increased levels of stigma (β = - 0.45, p = 0.013) and depression (β = - 0.09, p = 0.017) were both associated with a decline in medication adherence. Bootstrapping analysis revealed that the association between social support and medication adherence operated indirectly through stigma (β = 0.11, 95% CI: 0.03, 0.18). Additionally, social support was indirectly associated with medication adherence through depression (β = 0.15, 95% CI: 0.04, 0.30). Further analysis indicated that social support had an indirect association with medication adherence through both stigma and depression (β = 0.04, 95% CI: 0.01, 0.07).

Conclusion

Stigma and depression serially mediate the association between social support and medication adherence among patients with schizophrenia. This serial multiple mediation model underscores the importance of integrating social support interventions with psychological interventions aimed at reducing stigma and depression, thereby effectively enhancing medication adherence in patients with schizophrenia.

Stigma, depression, quality of life, and the need for psychosocial support among people with tuberculosis in Indonesia: A multi-site cross-sectional study

Stigma towards people with tuberculosis (TB-Stigma) is associated with other psychosocial consequences of TB including mental illness and reduced quality of life (QoL). We evaluated TB-Stigma, depression, QoL, and the need for psychosocial support among adults with TB in Indonesia, a high TB burden country. In this primary health facility-based survey in seven provinces of Indonesia, from February to November 2022, we interviewed adults receiving (a) intensive phase treatment for drug-susceptible (DS) TB at public facilities, (b) treatment at private facilities, (c) those lost to follow up (LTFU) to treatment, and (d) those receiving TB retreatment. We used our previously validated Indonesian TB-Stigma Scale, Patient Health Questionnaire-9, and EQ-5D-5L to measure TB-Stigma, depression, and QoL. Additional questions assessed what psychosocial support was received or needed by participants. We recruited and interviewed 612 people, of whom 60.6% (96%CI 59.6-64.5%) experienced moderate TB-Stigma. The average TB-Stigma scores were 19.0 (SD 6.9; min-max 0-50; Form A-Patient Perspective) and 23.4 (SD 8.4, min-max 0-50; Form B-Community Perspective). The scores were higher among people receiving treatment at private facilities (adjusted B [aB] 2.48; 0.94-4.03), those LTFU (aB 2.86; 0.85-4.87), males (aB 1.73; 0.59-2.87), those losing or changing job due to TB (aB 2.09; 0.31-3.88) and those living in a rural area (aB 1.41; 0.19-2.63). Depression was identified in 41.5% (95% CI 37.7-45.3%) of participants. Experiencing TB-Stigma was associated with moderately severe to severe depression (adjusted odds ratio [aOR] 1.23; 1.15-1.32) and both stigma and depression were associated with lower QoL (aB -0.013; [-0.016]-[-0.010]). Informational (20.8%), emotional (25.9%) and instrumental (10.6%) support received from peers or peer-groups was limited, and unmet need for such support was high. There is a sizeable and intersecting burden of TB-Stigma and depression among adults with TB in Indonesia, which is associated with lower QoL. Participants reported a substantial unmet need for psychosocial support including peer-led mutual support groups. A community-based peer-led psychosocial support intervention is critical to defray the psychosocial impact of TB in Indonesia.

The more the better? How social support predicted perceived barriers to tuberculosis treatment across groups of different socioeconomic statuses

OBJECTIVE

Social support can lower perceived barriers to medical treatment, but this relationship may vary in groups of different socioeconomic statuses (SES). This study examined whether different types of social support predicted different types of perceived barriers to tuberculosis (TB) treatment and whether these relationships varied across different levels of SES.

METHOD

A paper-pencil survey covering 12 cities in Guangdong, China (N = 1386) was conducted in December 2020, which measured demographics, three types of perceived social support (informational, instrumental, and emotional) and barriers to TB treatment (cognitive, instrumental, and psychological).

RESULTS

Informational support and instrumental support were negatively related to cognitive barriers and instrumental barriers. These relationships were stronger among more educated individuals and urban residents. However, emotional support predicted psychological barrier positively, and this relationship was stronger among less educated individuals and rural residents.

CONCLUSION

High SES groups benefit more from individual-level support. Thus, there is a gap of social support, which reveals the power nature of social support exchanges.

PRACTICE IMPLICATIONS

TB campaigns need provide support for low SES groups to compensate for their insufficient support. Campaigns need provide information about disease management and the legal and financial support for TB patients, and change tuberculosis-related norms.

Living with tuberculosis: a qualitative study of patients’ experiences with disease and treatment

Background

Although tuberculosis (TB) is a curable disease, treatment is complex and prolonged, requiring considerable commitment from patients. This study aimed to understand the common perspectives of TB patients across Brazil, Russia, India, China, and South Africa throughout their disease journey, including the emotional, psychological, and practical challenges that patients and their families face.

Methods

This qualitative market research study was conducted between July 2020 and February 2021. Eight TB patients from each country (n = 40) completed health questionnaires, video/telephone interviews, and diaries regarding their experiences of TB. Additionally, 52 household members were interviewed. Patients at different stages of their TB treatment journey, from a range of socioeconomic groups, with or without TB risk factors were sought. Anonymized data underwent triangulation and thematic analysis by iterative coding of statements.

Results

The sample included 23 men and 17 women aged 13–60 years old, with risk factors for TB reported by 23/40 patients. Although patients were from different countries and cultural backgrounds, experiencing diverse health system contexts, five themes emerged as common across the sample. 1) Economic hardship from loss of income and medical/travel expenses. 2) Widespread stigma, delaying presentation and deeply affecting patients’ emotional wellbeing. 3) TB and HIV co-infection was particularly challenging, but increased TB awareness and accelerated diagnosis. 4) Disruption to family life strained relationships and increased patients’ feelings of isolation and loneliness. 5) The COVID-19 pandemic made it easier for TB patients to keep their condition private, but disrupted access to services.

Conclusions

Despite disparate cultural, socio-economic, and systemic contexts across countries, TB patients experience common challenges. A robust examination of the needs of individual patients and their families is required to improve the patient experience, encourage adherence, and promote cure, given the limitations of current treatment.

Internalized and Perceived Stigma and Depression in Pulmonary Tuberculosis: Do They Explain the Relationship Between Drug Sensitivity Status and Adherence?

Background

Adherence to medication for tuberculosis (TB) has been found to be deleteriously affected by psychosocial issues, including internalized and perceived stigma (IPS) and depression, usually resulting in the emergence of multidrug-resistant TB (MDR-TB). The objective of the study was to find the prevalence of depression among patients receiving treatment for pulmonary TB, and how stigma and depression affect the relationship between drug sensitivity status (DSS) and treatment adherence.

Method

It was a cross-sectional observational study conducted between January 2019 and July 2020 in two centers in Sikkim, India. The Patient Health Questionnaire-9 (PHQ-9), Internalized Social Stigma Scale (ISSS), and Tuberculosis Medication Adherence Scale were used to assess depression, IPS, and medication adherence, respectively. A path analysis was performed with DSS, treatment adherence, IPS, and depression. Education in years was included in the model as it was significantly correlated with IPS.

Results

A total of 71 patients who were on drug-sensitive TB (DS-TB) regimen (n = 26) and MDR-TB regimen (n = 45) participated in the study. Notably, 56.3% (n = 40) of the participants were found to have depression. Among the depressed participants, 32.5% were on the DS-TB regimen and 67.5% were on the MDR-TB regimen. The path analysis indicated that IPS and depression were serially mediating the relationship between DSS and treatment adherence (β = -0.06, p < 0.05, 95% CI = -3.20, -0.02). Finally, years of education had an exogenous predictor role, not only directly affecting IPS (β = -0.38, p < 0.001, 95% CI = -0.99, -0.31) but also affecting treatment adherence through IPS and depression (β = 0.08, p = 0.02, 95% CI = 0.03, 0.47). This indicated that with more years of education, the IPS decreases, which decreases depression and ultimately leads to better adherence.

Conclusion

We found an important relationship between different psychosocial factors which may affect treatment adherence. Patients who have higher IPS are more likely to develop depression which negatively affect adherence. Patients on the MDR-TB regimen have higher stigma. There is an urgent need to integrate mental health services with TB Control Programs.

The relationship among social support, experienced stigma, psychological distress, and quality of life among tuberculosis patients in China

The complex relationships among social support, experienced stigma, psychological distress, and quality of life (QOL) among tuberculosis (TB) patients are insufficiently understood. The purpose of this study was to explore the interrelationships among social support, experienced stigma, psychological distress, and QOL and to examine whether experienced stigma and psychological distress play a mediating role. A cross-sectional survey was conducted between November 2020 and March 2021 in Dalian, Liaoning Province, Northeast China. Data were obtained from 473 TB patients using a structured questionnaire. Structural equation modelling was used to examine the hypothetical model. The research model provided a good fit to the measured data. All research hypotheses were supported: (1) social support, experienced stigma and psychological distress were associated with QOL; (2) experienced stigma fully mediated the effect of social support on psychological distress; (3) psychological distress fully mediated the effect of experienced stigma on QOL; and (4) experienced stigma and psychological distress were sequential mediators between social support and QOL. This study elucidated the pathways linking social support, experienced stigma, and psychological distress to QOL and provides an empirical basis for improving the QOL of TB patients.

Identifying contextual determinants of problems in tuberculosis care provision in South Africa: a theory-generating case study

BACKGROUND

Despite progress towards End TB Strategy targets for reducing tuberculosis (TB) incidence and deaths by 2035, South Africa remains among the top ten high-burden tuberculosis countries globally. A large challenge lies in how policies to improve detection, diagnosis and treatment completion interact with social and structural drivers of TB. Detailed understanding and theoretical development of the contextual determinants of problems in TB care is required for developing effective interventions. This article reports findings from the pre-implementation phase of a study of TB care in South Africa, contributing to HeAlth System StrEngThening in Sub-Saharan Africa (ASSET)-a five-year research programme developing and evaluating health system strengthening interventions in sub-Saharan Africa. The study aimed to develop hypothetical propositions regarding contextual determinants of problems in TB care to inform intervention development to reduce TB deaths and incidence whilst ensuring the delivery of quality integrated, person-centred care.

METHODS

Theory-building case study design using the Context and Implementation of Complex Interventions (CICI) framework to identify contextual determinants of problems in TB care. Between February and November 2019, we used mixed methods in six public-sector primary healthcare facilities and one public-sector hospital serving impoverished urban and rural communities in the Amajuba District of KwaZulu-Natal Province, South Africa. Qualitative data included stakeholder interviews, observations and documentary analysis. Quantitative data included routine data on sputum testing and TB deaths. Data were inductively analysed and mapped onto the seven CICI contextual domains.

RESULTS

Delayed diagnosis was caused by interactions between fragmented healthcare provision; limited resources; verticalised care; poor TB screening, sputum collection and record-keeping. One nurse responsible for TB care, with limited integration of TB with other conditions, and policy focused on treatment adherence contributed to staff stress and limited consideration of patients' psychosocial needs. Patients were lost to follow up due to discontinuity of information, poverty, employment restrictions and limited support for treatment side-effects. Infection control measures appeared to be compromised by efforts to integrate care.

CONCLUSIONS

Delayed diagnosis, limited psychosocial support for patients and staff, patients lost to follow-up and inadequate infection control are caused by an interaction between multiple interacting contextual determinants. TB policy needs to resolve tensions between treating TB as epidemic and individually-experienced social problem, supporting interventions which strengthen case detection, infection control and treatment, and also promote person-centred support for healthcare professionals and patients.

Health related quality of life and associated factors with medication adherence among tuberculosis patients in selected districts of Gandaki Province of Nepal

Background

Tuberculosis is one of the significant public health problems of Nepal. Adherence to medication is very important for improving quality of life and preventing complication. Adherence to tuberculosis medications has significant economic and therapeutic consequences as non-adherence patients are at greater risk of developing complications which affect their health status and overall quality of life. The study aims to determine the factors associated with medication adherence and its effect on health related quality of life among tuberculosis patients in selected districts of Gandaki Province.

Methods

A health facility based cross-sectional study was carried out among 180 tuberculosis patients registered under DOTS and receiving treatment more than or equal to 60 days. WHOQOL-BREF tools to assess quality of life and Morisky medication adherence scale (MMAS-8) was adopt to assess medication adherence. Data was entered in Epi-data and analysis was performed with the help of the Statistical Package for Social Science (SPSS). The odds ratio with a 95% CI was calculated and p-value of <0.05 was considered as cutoff for statistical significance.

Results

A total 180 TB patients were participated in this study. Overall quality of life ranges from 10.75 to 89.25 with Mean ± SD as 55.96 ± 14.65. More than three-fourth (79.4%) respondents were adhere to medication. Medication adherence and health related quality of life was found statistically significant with relationship with health workers, favourable time at DOTS centre, absence of co-infection. Participants who were highly adhered to medication had good quality of life.

Conclusion

Majority of tuberculosis patients adhering to medication had good quality of life. Especial emphasis should be given to tuberculosis patients with co-infection, health workers should behave friendly and provide appropriate counselling in order to maintain the medication adherence and quality of life.

Tuberculosis-related stigma and its determinants in Dalian, Northeast China: a cross-sectional study

Background

The stigma of tuberculosis (TB) poses a significant challenge to TB control because it leads to delayed diagnosis and non-adherence. However, few studies on TB-related stigma have been completed in China. The aim of the current study was to explore the status of TB-related stigma and its associated predictive factors among TB patients in Dalian, Northeast China.

Methods

An institution-based, cross-sectional survey was conducted among outpatients at Dalian Tuberculosis Hospital in Liaoning Province, Northeast China. Data were collected by using a questionnaire that measured TB-related stigma, treatment status, anxiety, social support, doctor-patient communication and so on. A multiple linear regression model was used to determine the predictors of TB-related stigma.

Results

A total of 601 eligible participants were recruited. The mean score for TB-related stigma was 9.07, and the median score was 10. The average scores for anxiety, social support and doctor-patient communication were 4.03, 25.41 and 17.17, respectively. Multiple linear regression analysis revealed that patients who were female (β = 1.19, 95% CI: 0.38–2.01, P < 0.05), had self-assessed moderate or severe disease (β = 1.08, 95% CI: 0.12–2.03 and β = 1.36, 95% CI: 0.03–2.70, respectively, P < 0.05), and had anxiety (β = 0.38, 95% CI: 0.30–0.46, P < 0.001) were more likely to have a greater level of TB-related stigma than their counterparts. However, a significantly lower level of TB-related stigma was observed in patients with good social support (β = − 0.25, 95% CI: − 0.33--0.17, P < 0.001) and doctor-patient communication (β = − 0.14, 95% CI: − 0.29--0.00, P < 0.05).

Conclusions

This study showed that stigma among TB patients was high. Targeted attention should be paid to female patients and patients with moderate or severe disease in TB stigma-related interventions. Moreover, the important role of social support and doctor-patient communication in reducing TB-related stigma should also be emphasized.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10055-2.

Social stigma among tuberculosis patients attending DOTS centers in Delhi

Background:

Every year >9 million people suffer from tuberculosis (TB) and India accounts for >25% of global TB burden. Tuberculosis patients experience both psychological and social suffering. Amongst the problems met by tuberculosis patients, social stigma has been increasingly recognized. This study was done to assess social stigma and associated factors among the tuberculosis patients attending Directly Observed Treatment Short-course (DOTS) centers in South East Delhi.

Material and Methods:

It was a cross-sectional study carried out among tuberculosis patients availing treatment from DOTS centers of South East Delhi. Out of 48 DOTS centers in South East Delhi, 6 centers were selected on the basis of population proportion to size. A total of 270 TB patients were interviewed using a semi-structured, pretested questionnaire consisting of stigma-based questions. Fisher exact and Chi-square test applied.

Results:

The mean age of patients was 31.5 years (SD ± 11.5) with age ranging from 18 to 77 years. Males were higher (57.4%) compared to females (42.6%). 123 (45.5%) perceived stigma with family/friends and 92/158 (58.2%) perceived stigma at workplace. Young patients (<30 years), males faced more stigma at workplace and lower socioeconomic class faced higher stigma with family and friends (P < 0.05).

Conclusion:

There is still higher stigmatization faced by patients with TB at family/friends and at workplace. Motivation by friends/family and support at workplace has been crucial in achieving successful treatment outcomes.