| Objective:Tuberculosis-related stigma is critical in Tuberculosis (TB) treatment success, this study aimed to develop and validate a Tuberculosis-related Stigma Scale, to assess the status of stigma among TB patients and to explore the potential influencing factors of TB related stigma. At the same time, we intended to explore the effect of TB related stigma on patients’compliance and to analyze the mediating effect of stigma.Methods:Tuberculosis-related Stigma Scale and questionnaire were developed based on comprehensive reviews of literature on stigma and an advisory panel organized to discuss the literature and relevant factors inTB related stigma. And then according to multistage sampling method, three TB prevention and control institutions were randomly selected in Hubei province. We conducted a questionnaire survey in the selected TB prevention and control institutions. All rural TB patients agreed to participate in study were interviewed by healthcare workers at the moment they visited the TB prevention and control institutions, finally,1342rural TB patients were interviewed during the period from October1,2013to March31,2014. Discrimination coefficient and spearman correlation analysis were used to screen redundant or non-informative items. The Cronbach’s alpha and confirmatory factor analysis were used to measure the reliability and validity of the Tuberculosis-related Stigma Scale; multiple linear regression analysis was conducted to explore the influencing factors of TB related stigma, structural equation modeling was adopted to analyze the effects of stigma on compliance and test the mediating effect of stigma. Statistical software SAS9.4and Amos17.0were employed for data analysis.Results:1. The development and validation of Tuberculosis-related Stigma Scale. The Tuberculosis-related Stigma Scale is a scale of3sub-scales including9items. The three sub-scales are:(1) negative experience,(2) emotional reactions, and (3) coping style. The Cronbach’s alpha was0.88for the entire scale suggesting good reliability; confirmatory factor analysis showed that theory factor structure of Tuberculosis-related Stigma Scale is matched with the sample data, which implied robust construct validity.2. The analysis of current situation and influencing factors of TB related stigma. The average score of the Tuberculosis-related Stigma Scale was9.33(standard deviation=4.25) among TB patients, and of the nine items,"reluctant to tell others that I has TB" and "avoid to socialize with others". Multiple linear regression analysis showed that, there was no significant correlation between TB related stigma and patients’socio-demographic characteristics such as sex, age, educational level, marital status and religious beliefs; while doctor-patient communications, patients’ knowledge about TB and family function were significantly negatively associated with patients’stigma.3. The effects of stigma on patients’ compliance and the mediating effect of stigma. The Morisky Medication Adherence Scale identified447(33.31%) of the1342patients as non-adherents. After controlling the effect of doctor-patient communications, patients’knowledge about TB and family function, the direct effect of stigma on patients’compliance was-0.28. Stigma was a mediator variable between doctor-patient communications, patients’ knowledge about TB as well as family function and patients’compliance, and its mediating effects accounted for20.00%,10.00%and20.69%, respectively of the total effect.Conclusion:Tuberculosis-related Stigma Scale has relatively high reliability and validity, which can be used as an effective tool to measure TB patients’ stigma. However, it is necessary to carry out further empirical research to confirm the reliability, validity and the value of Tuberculosis-related Stigma Scale. Reluctance to disclose disease status and being socially withdrawn were the main features of stigma among TB patients. The relationship between social demographic characteristics and TB patients’stigma was not significant; while good doctor-patient communications, patients’ knowledge about TB and good family function had a positive effect on relieving patients’stigma, and the family function had the most significant effect. TB related stigma not only had direct effect on patients’compliance, but also played as a mediator variable between doctor-patient communications, patients’ knowledge about TB as well as family function and patients’ compliance. Therefore, it is necessary to strengthen the identification and intervention of TB related stigma in TB prevention and control process; in addition, we should pay attention to the role of family support for TB patients.Highlights and limitations:We developed the first Chinese tuberculosis-related stigma scale, and quantitatively measured patients’stigma related to TB by the developed scale. Additionally, we tested and confirmed the mediating effect of stigma in the relationship between doctor-patient communications, patients’knowledge about TB as well as family function and patients’compliance by structural equation modeling and it is the first time to point out the mechanism from the perspective of stigma. Several limitations of this study should to be noted. First, the validation study was conducted only in rural areas of a province, and may not be representative of TB patients from urban areas or other socio-economically different areas. These limitations could be addressed in the future when Tuberculosis-related Stigma Scale is used in the field and evaluated in TB patients in different areas. Second, doctor-patient communication was not assessed by common doctor-patient communication measurement scale but four items designed by the research group. |
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