The Mediating Effects Of Stigma On Depressive Symptoms In Patients With Tuberculosis:A Structural Equation Modeling

Objectives: This study aimed to assess the status of depressive symptoms in patients with tuberculosis and to identify the potential influencing factors of depressive symptoms.Meanwhile,we explored the association between family function,knowledge about tuberculosis,doctor-patient communication,tuberculosis-related stigma,and depressive symptoms,and examined the mediating effect of tuberculosis-related stigma.The findings of the research provide empirical evidence for depression interventions among patients with TB.Methods: Structured questionnaire were developed based on comprehensive reviews of literature and an advisory panel.Then three tuberculosis prevention and control institutions were randomly selected in Hubei province using a multistage sampling method.A cross-sectional survey was conducted in the selected tuberculosis prevention and control institutions from October 1,2013 to March 31,2014.Finally,a total of 1342 valid questionnaires were collected.Multiple linear regression method was used to identify the risk factors of depressive symptoms in patients with TB.Structural equation model was used to explore the interrelationships between family function,knowledge about tuberculosis,doctor-patient communication,tuberculosis-related stigma and depressive symptoms,and validate the mediating effect of stigma.All data analyses were performed using statistical software SAS9.3 and Amos 17.0.Results:1.Current status of depressive symptoms among tuberculosis patients.Of the 1,342 tuberculosis patients included in this study,the average score of the Depressive Symptoms Scale was 15.86(standard deviation = 8.19)and the prevalence of depre ssion symptoms was 48%.Of these,34.8% had mild while 13.2% had moderate to severe depressive symptoms.2.Influencing factors of depressive symptoms among tuberculosis patients.Multivariate analysis showed that depressive symptoms in tuberculosis patients had significant differences in socio-demographic characteristics.Female(?=1.13,P=0.0054)and minority(?=2.22,P<0.0001)patients are more likely to have depressive symptoms.Compared to patients with primary education level or below,patients with secondary education level(? =-1.25,P=0.0071),high school education level or above(? =-2.54,P=0.0001)are less likely to have depressive symptoms.In addition,family function,knowledge about tuberculosis,and doctor-patient communication were significantly negatively associated with patients’ depression symptoms,while tuberculosis-related stigma was significantly positively associated with patients’ depression symptoms.3.The effects of stigma on depressive symptoms and the mediating effect of stigma.Results of structural equation model showed that tuberculosis-related stigma had a significant direct effect on depressive symptoms,and the effect value was 0.219(P < 0.001).In addition,stigma partially mediated the effect of family function and knowledge about tuberculosis on depressive symptoms,and the mediating effect value was-0.048(P<0.01)and-0.021(P<0.01),accounted for 12.44% and 8.86% of the total effect,respectively.Stigma fully mediated the effect of doctor-patient communication on depressive symptoms,and the effect value was-0.028(P<0.01).Conclusion: Depressive symptoms are common among rural tuberculosis patients in China.Good family function,knowledge about tuberculosis,and doctor-patient communication are protective factors but tuberculosis-related stigma is a risk factor for depressive symptoms.Moreover,the effect of family function,knowledge about tuberculosis and doctor-patient communication on depressive symptoms can be mediated by tuberculosis-related stigma.Highlights and limitations: To the best of our knowledge,this was the first study to explore the complex interrelationships between family function,knowledge about tuberculosis,doctor-patient communication,tuberculosis-related stigma,and depressive symptoms.In addition,this was the first study to validate the effects of stigma on depressive symptoms and the mediating effect of stigma.There are a few limitations of this study that must be noted.Firstly,as a cross-sectional study,causality cannot be inferred.Secondly,our sample only comprised patients with TB in Hubei province,further studies in other provinces are needed.