Volume 100, Issue 1
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Stigma has been associated with health-related outcomes such as medication adherence and quality of life (QOL) in patients with tuberculosis (TB); however, the mechanisms via which TB-related stigma interferes with specific outcomes are unclear. This study aimed to determine whether depressive symptoms were one of the mechanisms that mediated the associations between TB-related stigma and both medication adherence and QOL in patients with TB. A cross-sectional survey was conducted between October 1, 2013, and March 31, 2014, in Hubei Province, central China, and data were collected from 1,342 patients with TB, using a structured questionnaire that measured TB-related stigma, depressive symptoms, medication adherence, and QOL. Multiple imputation was used to account for missing data. Structural equation modeling was performed to assess the mediating effect of depressive symptoms on the associations of TB-related stigma with medication adherence and QOL. Mediation analyses showed that depressive symptoms partially mediated the association between TB-related stigma and medication adherence (standardized indirect effect = −0.16, 95% bias-corrected confidence interval [CI] [−0.19, −0.13], < 0.01). Moreover, depressive symptoms fully mediated the association between TB-related stigma and QOL (standardized indirect effect = −0.17, 95% bias-corrected CI [−0.21, −0.14], < 0.01). The results suggest that depressive symptoms played a key role in the relationships among TB-related stigma, medication adherence, and QOL in patients with TB. Therefore, the alleviation of depressive symptoms could be an important strategy for improving medication adherence and QOL in patients with TB.


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  1. World Health Organization, 2016. Global Tuberculosis Report 2016. Geneva, Switzerland: WHO. [Google Scholar]
  2. Woith WM, Larson JL, , 2008. Delay in seeking treatment and adherence to tuberculosis medications in Russia: a survey of patients from two clinics. Int J Nurs Stud 45: 11631174. [Google Scholar]
  3. Tachfouti N, Slama K, Berraho M, Nejjari C, , 2012. The impact of knowledge and attitudes on adherence to tuberculosis treatment: a case-control study in a Moroccan region. Pan Afr Med J 12: 52. [Google Scholar]
  4. Munro SA, Lewin SA, Smith HJ, Engel ME, Fretheim A, Volmink J, , 2007. Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Med 4: e238. [Google Scholar]
  5. Kastien-Hilka T, Rosenkranz B, Bennett B, Sinanovic E, Schwenkglenks M, , 2016. How to evaluate health-related quality of life and its association with medication adherence in pulmonary tuberculosis—designing a prospective observational study in South Africa. Front Pharmacol 7: 125. [Google Scholar]
  6. Link BG, Phelan JC, , 2006. Stigma and its public health implications. Lancet 367: 528529. [Google Scholar]
  7. Chang SH, Cataldo JK, , 2014. A systematic review of global cultural variations in knowledge, attitudes and health responses to tuberculosis stigma. Int J Tuberc Lung Dis 18: 168173. [Google Scholar]
  8. Anand T, Kumar DA, Sharma N, Saha R, Krishnamurthy L, Singh SV, Ingle GK, , 2014. Perception of stigma towards TB among patients on DOTS & patients attending general OPD in Delhi. Indian J Tuberc 61: 3542. [Google Scholar]
  9. Sabawoon W, Sato H, Kobayashi Y, , 2012. Delay in the treatment of pulmonary tuberculosis: a report from Afghanistan. Environ Health Prev Med 17: 5361. [Google Scholar]
  10. Peddireddy V, , 2016. Quality of life, psychological interventions and treatment outcome in tuberculosis patients: the indian scenario. Front Psychol 7: 1664. [Google Scholar]
  11. Kastien-Hilka T, Abulfathi A, Rosenkranz B, Bennett B, Schwenkglenks M, Sinanovic E, , 2016. Health-related quality of life and its association with medication adherence in active pulmonary tuberculosis—a systematic review of global literature with focus on South Africa. Health Qual Life Outcomes 14: 42. [Google Scholar]
  12. Li Y, Ehiri J, Tang S, Li D, Bian Y, Lin H, Marshall C, Cao J, , 2013. Factors associated with patient, and diagnostic delays in Chinese TB patients: a systematic review and meta-analysis. BMC Med 11: 156. [Google Scholar]
  13. Goffman E, , 1963. Stigma: Notes on the Management of Spoiled Identity. New York, NY: Simon & Schuster. [Google Scholar]
  14. McArthur E, Bali S, Khan AA, , 2016. Socio-cultural and knowledge-based barriers to tuberculosis diagnosis for women in Bhopal, India. Indian J Community Med 41: 6264. [Google Scholar]
  15. Duko B, Gebeyehu A, Ayano G, , 2015. Prevalence and correlates of depression and anxiety among patients with tuberculosis at WolaitaSodo University Hospital and Sodo Health Center, WolaitaSodo, south Ethiopia, cross sectional study. BMC psychiatry 15: 214. [Google Scholar]
  16. Sagili KD, Satyanarayana S, Chadha SS, , 2016. Is knowledge regarding tuberculosis associated with stigmatising and discriminating attitudes of general population towards tuberculosis patients? Findings from a community based survey in 30 districts of India. PLoS One 11: e0147274. [Google Scholar]
  17. Lee LY, Tung HH, Chen SC, Fu CH, , 2017. Perceived stigma and depression in initially diagnosed pulmonary tuberculosis patients. J Clin Nurs 26: 48134821. [Google Scholar]
  18. Singh L, Pardal PK, Prakash J, , 2015. Psychiatric morbidity in patients of pulmonary tuberculosis-an observational study. Ind Psychiatry J 24: 168171. [Google Scholar]
  19. Mason PH, Sweetland AC, Fox GJ, Halovic S, Nguyen TA, Marks GB, , 2016. Tuberculosis and mental health in the Asia-Pacific. Australas Psychiatry 24: 553555. [Google Scholar]
  20. Pan SW, Yen YF, Feng JY, Su VYF, Kou YR, Su WJ, , 2015. The risk of depressive disorder among contacts of tuberculosis patients in a TB-endemic area: a population-based cohort study. Medicine 94: e1870. [Google Scholar]
  21. Dos Santos APC, Lazzari TK, Silva DR, , 2017. Health-related quality of life, depression and anxiety in hospitalized patients with tuberculosis. Tuberc Respir Dis (Seoul) 80: 6976. [Google Scholar]
  22. Kehbila J, Ekabe CJ, Aminde LN, Noubiap JJN, Fon PN, Monekosso GL, , 2016. Prevalence and correlates of depressive symptoms in adult patients with pulmonary tuberculosis in the southwest region of Cameroon. Infect Dis Poverty 5: 51. [Google Scholar]
  23. Pachi A, Bratis D, Moussas G, Tselebis A, , 2013. Psychiatric morbidity and other factors affecting treatment adherence in pulmonary tuberculosis patients. Tuberc Res Treat 2013: 489865. [Google Scholar]
  24. Shapiro-Mendoza CK, , 2014. Commentary: mediation and moderation analyses: a novel approach to exploring the complex pathways between maternal medical conditions, preterm birth and associated newborn morbidity risk. Int J Epidemiol 43: 815817. [Google Scholar]
  25. Harel O, Mitchell EM, Perkins NJ, Cole SR, Tchetgen Tchetgen EJ, Sun B, Schisterman EF, , 2018. Multiple imputation for incomplete data in epidemiologic studies. Am J Epidemiol 187: 576584. [Google Scholar]
  26. Lee KJ, Carlin JB, , 2012. Recovery of information from multiple imputation: a simulation study. Emerg Themes Epidemiol 9: 3. [Google Scholar]
  27. Yang TT, Tong YQ, YIn XX, Lu ZX, Gong YH, , 2016. Evaluation of Morisky medication aherence scale and family APGAR applied to patients with tuberculosis. Chin J Social Med 33: 580582. [Google Scholar]
  28. Radloff LS, , 1977. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1: 385401. [Google Scholar]
  29. Zhang J, Sun W, Kong Y, Wang C, , 2012. Reliability and validity of the center for epidemiological studies depression scale in 2 special adult samples from rural China. Compr Psychiatry 53: 12431251. [Google Scholar]
  30. Morisky DE, Ang A, Krousel-Wood M, Ward HJ, , 2008. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 10: 348354. [Google Scholar]
  31. Yan J, You LM, Yang Q, Liu B, Jin S, Zhou J, Lin C, Monrisky DE, , 2014. Translation and validation of a Chinese version of the 8-item Morisky medication adherence scale in myocardial infarction patients. J Eval Clin Pract 20: 311317. [Google Scholar]
  32. Phillips MR, Yang G, Zhang Y, Wang L, Ji H, Zhou M, , 2002. Risk factors for suicide in China: a national case-control psychological autopsy study. Lancet 360: 17281736. [Google Scholar]
  33. Preacher KJ, Hayes AF, , 2008. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods 40: 879891. [Google Scholar]
  34. Hu L, Bentler PM, , 1999. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model 6: 155. [Google Scholar]
  35. Kenny DA, McCoach DB, , 2003. Effect of the number of variables on measures of fit in structural equation modeling. Struct Equ Model 10: 333351. [Google Scholar]
  36. Li CT, Chu KH, Reiher B, Kienene T, Chien LY, , 2017. Evaluation of health-related quality of life in patients with tuberculosis who completed treatment in Kiribati. J Int Med Res 45: 610620. [Google Scholar]
  37. Mitzel LD, Vanable PA, Brown JL, Bostwick RA, Sweeney SM, Carey MP, , 2015. Depressive symptoms mediate the effect of HIV-related stigmatization on medication adherence among HIV-infected men who have sex with men. AIDS Behav 19: 14541459. [Google Scholar]
  38. Rao D, Feldman BJ, Fredericksen RJ, Crane PK, Simoni JM, Kitahata MM, Crane HM, , 2012. A structural equation model of HIV-related stigma, depressive symptoms, and medication adherence. AIDS Behav 16: 711716. [Google Scholar]
  39. Ambaw F, Mayston R, Hanlon C, Alem A, , 2015. Depression among patients with tuberculosis: determinants, course and impact on pathways to care and treatment outcomes in a primary care setting in southern Ethiopia—a study protocol. BMJ Open 5: e007653. [Google Scholar]
  40. Hafeman DM, Schwartz S, , 2009. Opening the black box: a motivation for the assessment of mediation. Int J Epidemiol 38: 838845. [Google Scholar]
  41. Brunner J, Austin PC, , 2009. Inflation of type I error rate in multiple regression when independent variables are measured with error. Can J Stat 37: 3346. [Google Scholar]

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  • Received : 16 Apr 2018
  • Accepted : 28 Sep 2018
  • Published online : 05 Nov 2018

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