Stigma associated with mental stress and reduced quality of life among HIV-infected women in western China:a cross-sectional study

doi:10.21203/rs.3.rs-2607141/v1

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Stigma associated with mental stress and reduced quality of life among HIV-infected women in western China:a cross-sectional study

https://doi.org/10.21203/rs.3.rs-2607141/v1

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Background: Stigma has been identified as a crucial risk factor for mental stress and quality of life among HIV-infected patients. However, little attention has been paid to these factors among Asian populations and women rendered vulnerable by their psychological characteristics. In addition, the relationships between stigma, social capital, mental stress and quality of life remain to be elucidated.

Methods: A total of 553 HIV-infected women were recruited in Xijiang, China from September 2021 to August 2022. Stigma was assessed using the 12-item Short HIV Stigma scale; mental stress (anxiety, depression) was assessed using the 20-item Self-Rating Anxiety scale (SAS) and 10-item Center for Epidemiological Studies Depression (CESD) scale; social capital was assessed using the Personal Social Capital Scale (PSCS-8);quality of lifewas assessed using the WHO QOL-HIV-BREF scale.

A generalized linear model (GLM) and structural equation model (SEM) were used to examine the associations between stigma, social capital, mental stress and quality of life.

Results: The HIV-related stigma scale showed actual discrimination score 6.57±2.56, fear of publicity score 7.31±2.34, public attitude score 6.56±2.52, and negative self-image score 6.74±2.55. Quality of life scores were 11.87±2.33 (physiological domain), 9.91±2.42 (psychological domain), 13.31±3.17 (social relation domain) and 11.19±2.84 (environmental domain). SAS-20 and CESD-10 scores were 81.25±50.11 and 9.02±5.55, respectively. After adjusting for age, education, marital status, employment status, residence and monthly income, each 10-point increase in stigma score was associated with 49.3% (OR=1.493, 95%CI:1.218, 1.840) and 51.5% (OR=1.515, 95%CI:1.235, 1.868) increases in anxiety symptoms and depression risk, respectively. In the SEM, stigma was associated with mental stress (β=0.25, p=0.014), which decreased the quality of life of HIV-positive women (β=0.17, p=0.032). The direct effect of social capital on mental stress was significant (β=0.18, p=0.033).

Conclusion: Stigma and depression play important roles in quality of life among HIV-infected women. Immediate measures should be taken to reduce stigma and provide psychological guidance, which might contribute to decreasing mental stress and improving quality of life among HIV-infected women.

Biological sciences/Psychology

Health sciences/Diseases/Immunological disorders

stigma

depression

quality of life

social capital

HIV/AIDS

With global effort and the application of antiretroviral therapy, the physiological health of acquired immunodeficiency syndrome (AIDS) patients has been greatly improved (1–2). However, human immunodeficiency virus (HIV)-related effects on mental stress and quality of life have become increasingly major public health challenges and bring a heavy burden to society (3–4). Epidemiological studies have confirmed that the prevalence of high mental stress and low quality of life are significantly higher among female than male HIV-infected patients (5). Moreover, compared with male patients, women have psychological characteristics which make them relatively vulnerable to mental stress and negative impact on quality of life, including fear of mother-to-child HIV transmission, and risk of stigma and violence (6–8). Identification of the risk factors for negative impacts on mental stress and quality of life is crucial to promoting the health of HIV-infected women.

HIV-related stigma is defined as the shame or disgrace attached to AIDS and is expressed through negative social reactions towards HIV-infected patients (3). Existing global evidence shows that HIV-related stigma is a serious threat to achieving the 90-90-90 and 95-95-95 targets, which have been proposed as steps toward ending the AIDS epidemic by 2030 (9). Previous studies showed that HIV-related stigma was associated with increased risk of mental stress and quality of life (10–13). In these studies, anxiety and depression were the most common psychosocial factors (14). For example, a cross-sectional study of 4050 United States-based HIV-infected adults found that each 1-point increase in stigma score was associated with a 39% (OR = 1.39, 95%CI: 1.33, 1.44) increase in anxiety risk and 35% (OR = 1.35, 95%CI: 1.29, 1.42) increase in depression risk (15). A cross-sectional study of 417 patients with HIV in Ethiopia showed that perceived HIV stigma was significantly associated with increased risk of anxiety (OR = 4.00, 95%CI:2.40, 6.69) and depression (OR = 3.60, 95%CI:2.23, 5.80) (12). A recent meta-analysis found that individuals with HIV-related stigma were 1.83 times (OR = 1.83, 95%CI: 1.24, 2.41) more likely to have suicidal ideation (10). Most studies in this field have been conducted in Africa and among man who have sex with men, with little attention being paid to Asian populations and women with psychological characteristics that make them vulnerable.

Mental stress has been identified as the most common risk factor for reduced quality of life (16–19). For example, a cross-sectional study of 86 HIV-infected adults found that each 1-point increase in the Symptoms Check List 90 (SCL-90) depressive symptoms T-score was associated with a 26% (OR = 1.26, 95%CI: 1.08, 1.48) increase in suicidal ideation, whereas no significant association was observed with the corresponding anxiety score (18). Moreover, people with quality of life attempts are more likely to suffer anxiety and depression. For example, a Chinese cross-sectional study of 995 individuals living with HIV found those who had suicidal ideation or quality of life were more likely to report anxiety (Quality of life ideation: OR = 2.80, 95%CI:1.77, 4.42; Quality of life attempt: OR = 5.62, 95%CI: 1.55, 20.4) and depression (Quality of life ideation: OR = 2.43, 95%CI:1.51, 3.88; Quality of life attempt: OR = 4.44, 95%CI: 1.22, 16.1) than those without any suicidal behavior (20).

In addition to the limited studies about Asian populations or women in this field, previous studies have used t-tests, chi-square tests and logistic regression (19) but the direct and indirect effects of stigma and mental stress have not been fully understood. The structural equation model (SEM) is an effective method to assess the direct and indirect effects of psychological factors on health outcomes (21).

The purpose of this study was therefore to examine the relationship between HIV-related stigma, mental stress and quality of life among Asian HIV-infected women. We hypothesized that: (1) HIV-related stigma increases the risk of mental stress (anxiety, depression) and reduced quality of life; (2) Mental stress (anxiety, depression) increases the risk of reduced quality of life; (3) Mental stress (anxiety, depression) is a significant factor in the association between stigma and quality of life. To achieve these aims we developed a generalized linear model (GLM) and SEM.

2.1 Study population

All methods were performed in according with the relevant guidelines and regulations.The Xijiang HIV- infected Women Cohort Study was conducted at anti-AIDS virus treatment locations from September 2021 to August 2022. Inclusion criteria were: (1) HIV infected women confirmed by the Centers for Disease Control and Prevention; (2) those seeking treatment at designated antiviral treatment institutions in Xinjiang, China; (3) conscious, able to read, understand and answer questions normally; (4) agreement to participate and provision of signed informed consent. Exclusion criteria were: (1) Critically ill patients, unable to receive the survey and complete the questionnaire; (2) mentally ill or mentally deficient, unable to cooperate with investigators; (3) serious AIDS-related complications. The cluster random sampling method was adopted to select all the infected women of child-bearing age in the AIDS case bank at two antiviral treatment sites in Xinjiang, and a random number table was used to select eligible participants. A total of 553 patients were randomly selected.

2.2 Method of recruitment

Project leaders of various antiviral treatment sites in Xinjiang, China, raised awareness of this research among AIDS patients. Before participating, all subjects were required to sign a declaration of informed consent, indicating their voluntary participation in the study. The investigator fully informed the subjects of potential benefits from the study, including knowledge of HIV infection and treatment and timely detection of psychological problems. The personal information of the research subjects and the results of the questionnaire are strictly confidential, and the investigators are required to undergo security training and sign confidentiality agreements.

The study protocol was approved by the Institutional Review Board at Maternity and Child Care Hospital in Urumqi (Code: XJFYLL2021033) and a signed declaration of informed consent was obtained from all participants.

2.3 Stigma, Mental stress and Quality of life assessment

Stigma, mental stress (anxiety and depression) and quality of life were investigated using an anonymous self-administrated questionnaire. Two trained and qualified investigators were assigned to each designated treatment facility (A city and B city) to answer questions about the questionnaire and help illiterate individuals to participate.

2.3.1 Stigma. HIV related stigma was assessed by using the 12-item Short HIV Stigma scale, which was developed from the 40-item version (22–23) and has been adopted widely in studies on mental health of HIV-infected patients (24–26). Briefly, the 12-item Short HIV Stigma scale consists of four parts focused on: personalized stigma (3 items), disclosure concerns (3 items), concerns with public attitudes (3 items), and negative self-image (3 items). Participants were asked about their feelings and each item was scored as 1 (completely disagree), 2 (disagree), 3 (agree), or 4 (completely agree). The total score on this scale ranges from 12 to 48, and a higher stigma score indicates a more severe stigma status.

2.3.2 Mental stress. Depression status was assessed using the 10-item Center for Epidemiological Studies Depression scale (CESD-10), which was developed from the 20-item CESD version and has been used widely in mental health studies (21, 27). Participants were asked to rate how often they had experienced depressive symptoms in the last week. Each negative item (items 1–4, 6, 7, 9 and 10) was scored as 3 (most or all of the time (5–7 days)), 2 (occasionally or a moderate amount of the time (3–4 days)), 1 (some or a little of the time (1–2 days)), or 0 (rarely or none of the time (< 1 day)), while two positive items (items 5 and 8) were scored as 0 (most or all of the time (5–7 days)), 1 (occasionally or a moderate amount of the time (3–4 days)), 2 (some or a little of the time (1–2 days)), or 3 (rarely or none of the time (< 1 day)). The total score on the CESD-10 ranges from 0 to 30 and higher total score indicates more severe depression status. To evaluate the association between stigma and depression, we recognized participants as having symptoms of depression if their CESD-10 score was ≥ 10 (28–29). The Cronbach’s alpha coefficient was 0.789.

2.3.3 Quality of life. The WHO QOL-HIV-BREF scale was used in the study. This scale is based on the WHO QOL-BREF (Chinese version), with five items targeting HIV infected persons translated and added to form the WHO QOL-HIV-BREF scale. The scale contains 31 items and can be used to investigate individuals’ feelings over the past two weeks. Among these items, two assess the individual's overall quality of life and health, and the other 29 items evaluate physical, psychological, social relationship, environmental and spiritual support/personal belief domains of quality of life. Each item uses a Likert 5-point scale.

2.4 Covariates

Numerous potential confounders were considered in this study, including age, monthly income, residential location, educational level, marital status, and employment status. Residential location was categorized as urban or rural. Educational level was categorized as low (elementary school or below), moderate (middle or high school), or high (associate degree, college and above). Marital status was classified into three groups (unmarried, married or divorced/ widowed) and employment status into employed or unemployed.

2.5 Statistical analysis

Descriptive analyses were conducted on demographic characteristics, stigma, anxiety, depression and quality of life. Continuous variables are described as mean ± standard deviation (SD) and categorical variables are reported as count data and percentages. Pearson’s correlation test was applied to examine the correlations between stigma, anxiety and depression scores. As described below, a two-stage analysis was developed to assess the relationships between stigma, mental stress (anxiety and depression) and quality of life.

In the first stage, we estimated the associations between stigma and the risk of anxiety symptoms, depression symptoms and quality of life using a GLM. The effect estimates and 95% confidence intervals (95% CI) are presented as the odds ratios (OR) for these measures per 10-point increase in stigma score. The associations between mental stress (anxiety and depression) and quality of life were estimated with 95% CI and are presented as the OR for quality of life per 10-point increase in anxiety and depression scores. Crude and adjusted models were then developed, the former with covariates and the latter adjusted for age, monthly income, residential location, educational level, marital status, and employment status.

In the second stage, a SEM was used to assess the relationships between stigma, mental stress (anxiety and depression) and quality of life (30). Both direct and indirect effects are expressed as the standardized regression coefficient (β) and 95%CI, and bivariate analysis was employed to assess the associations between all variables (13). Relative chi-square (χ²/df), goodness-of-fit index (GFI), comparative fit index (CFI), Tucker-Lewis fit index (TLI) and the root mean-square error of approximation (RMSEA) were used to assess model fit (31).

GLM analysis was conducted using R software version 4.2.1 and SEM analysis was performed using SPSS AMOS module 20.0. A two-tailed p value < 0.05 was regarded as statistically significant.

3.1 Descriptive statistics

A total of 553 HIV-positive women were included in our study. The mean age of participants was 36.70 ± 7.48 years. Most of the participants reported moderate education levels (62.65%), were married (56.60%) and unemployed (66.37%). The average monthly income was 1771.75 ± 2518.64 RMB. Moreover, 58.23% of the participants were recruited from urban areas. More detailed demographic information is shown in Table 1.

Table 1

Demographic characteristics of participants
Characteristics	Mean/n	SD/%
Age (years) ^a	36.70	7.48
Income (RMB) ^a	1771.75	2518.64
Education ^b
Low	160	28.93
Moderate	346	62.56
High	47	8.51
Marital status ^b
Single	41	7.41
Married	313	56.60
Divorced, or widowed	199	35.99
Employment status ^b
Employed	186	33.63
Unemployed	367	66.37
Residence ^b
Urban	322	58.23
Rural	231	41.77
Health care type^b
Worker health	108	19.50
Resident medical insurance/New rural cooperative Medical system	397	71.80
Commercial insurance	5	0.90
Other	16	2.90
No insurance	27	4.90
HIV infection status^b
Cause of infection
Heterosexual sexual behavior	362	65.50
Homosexual sexual behavior	29	5.20
Paid blood donation	2	0.40
Blood transfusion or blood products	8	1.40
Drug use	25	4.50
Don't know	127	22.90
Duration of infection	362	65.50
< 12 months	29	5.20
12 months or more	2	0.40
^a For continuous variables, numbers represent the mean ± standard deviation; ^b For categorical variables, numbers represent count (percentage).

Table 2 presents the descriptive characteristics of stigma, anxiety, depression and quality of life. The average HIV-related stigma score is reported for each of four dimensions. The actual discrimination score was 6.57 ± 2.56, the fear of publicity score was 7.31 ± 2.34, the public attitude score was 6.56 ± 2.52, and the negative self-image score was 6.74 ± 2.55. The social capital score was categorized as low (n = 53; 9.6%) or high (n = 500; 90.4%). Quality of life measures were 11.87 ± 2.33 (physiological domain), 9.91 ± 2.42 (psychological domain), 13.31 ± 3.17 (social relation domain) and 11.19 ± 2.84 (environmental domain). The mean SAS-20 (anxiety) and CESD-10 (depression) scores were 81.25 ± 50.11 and 9.02 ± 5.55, respectively. Almost half (44.85%) of HIV-infected women had anxiety symptoms and 42.13% had depressive symptoms.

Table 2

Descriptive characteristics of stigma, mental stress and quality of life
Variable	Mean/n	SD/%
Stigma
Actual discrimination	6.57	2.56
Worry public	7.31	2.34
Public attitudes	6.56	2.52
Negative self-image	6.74	2.55
Anxiety
Anxiety Score: SAS-20	81.25	50.11
Anxiety symptom identification
No anxiety symptom	305	55.15
Anxiety symptom	248	44.85
Depression
Depression score: CESD-10	9.02	5.55
Depressive symptom identification
No depressive symptom	320	57.87
Depressive symptom	233	42.13
Quality of life
Physiological	11.87	2.33
Psychological	9.91	2.42
Social relations	13.31	3.17
Environment	11.19	2.84
Social capital
Lower	53	9.60
Higher	500	90.40

3.2 Associations between stigma and mental stress or quality of life

The associations between stigma scores and anxiety symptoms, depression symptoms or quality of life are shown in Table 3. We found that stigma score was positively associated with risk of anxiety and depression symptoms in the crude and adjusted models. After adjusting for age, education, marital status, employment status, residential location and monthly income, each 10-point increase in stigma score was associated with a 49.3% (OR = 1.493, 95%CI:1.218, 1.840) and 51.5% (OR = 1.515, 95%CI:1.235, 1.868) increase in anxiety and depression risk, respectively. No statistically significant association was observed between stigma score and quality of life.

Table 3

Associations between stigma score and mental stress (anxiety, depression) or quality of life
Models	Crude model		Adjusted model
Models	OR and 95%CI	P	OR and 95%CI	P
Anxiety	1.553 (1.227, 1.900)	< 0.001 ^***	1.493 (1.218, 1.840)	< 0.001 ^***
Depression	1.582 (1.299, 1.940)	< 0.001 ^***	1.515 (1.235, 1.868)	< 0.001 ^***
Quality of life	0.813 (0.563, 1.214)	0.534	0.889 (0.624, 1.210)	0.478

3.3 Associations between psychological status and quality of life

We also examined the associations between depression score and quality of life, and found that higher levels of depression were associated with lower quality of life. After adjusting for potential confounders, we observed that each 10-point increase in depression score was associated with a 30.4% (OR = 1.304, 95%CI: 1.014, 1.671) decrease in quality of life, and each 10-point increase in depression score was associated with an 81.6% (OR = 1.816, 95%CI: 1.142, 2.859) increase in suicidal ideation risk (Table 4).

Table 4

Associations between stigma score and both anxiety and depression scores
Models	Crude model		Adjusted model
Models	OR and 95%CI	P	OR and 95%CI	P
Anxiety	1.325 (1.045, 1.677)	0.019 ^*	1.304 (1.014, 1.671)	0.036 ^*
Depression	1.799 (1.158, 2.769)	0.008 ^**	1.816 (1.142, 2.859)	0.011 ^*

3.4 Structural equation model analysis of stigma, mental stress and quality of life.

Stigma was associated with mental stress (β = 0.25, p = 0.014), which decreased the quality of life of HIV-positive women (β = 0.17, p = 0.032). The indirect effect of stigma on social capital was not significant (β=-0.01, p = 0.885). The final SEM model indicated a good fit (χ2/df = 2.556, p < 0.001, CMIN/DF = 6.890, RFI = 0.962, CFI = 0.938, NFI = 0.987, TLI = 0.879, RMSEA = 0.103).The path coefficients of each variable are shown in Fig. 1。

The GLMs showed that higher stigma score was associated with higher risk of anxiety and depression symptoms, and that higher anxiety and depression scores were both associated with increased risk to quality of life. Consistent with these findings, the SEM model also showed significant associations between stigma and both mental stress (anxiety and depression) and quality of life, and between mental stress (anxiety and depression) and quality of life. Moreover, the SEM indicated that the association between stigma and suicidal ideation was mediated by mental stress (anxiety and depression). To our knowledge, this study is the first to explore the relationship between stigma, mental stress (anxiety and depression) and quality of life among HIV-infected women.

In this study, we found that stigma is significantly associated with mental stress, including anxiety and depression. Similar associations have also been observed in other studies (10, 32–34). For example, a recent meta-analysis of people living with HIV reported that those diagnosed with anxiety or depression were 1.30 (95%CI: 1.16, 1.43) or 1.61 (95%CI: 1.38, 1.83) times more likely, respectively, to report HIV-related stigma (32). Felker-Kantor et al. conducted a longitudinal study in New Orleans and found that higher levels of HIV-related stigma were associated with anxiety symptoms (relative risk (RR) = 1.91, 95%CI: 1.17, 3.12) and depression symptoms (RR = 1.67, 1.25, 2.23) (34). One potential explanation for these findings is that HIV-related stigma can contribute to a sense of social isolation and perceived lack of social support, which subsequently exacerbates anxiety and depression symptoms (13, 35–36). While no significant association between HIV-related stigma and suicidal ideation was observed in the present study, several previous studies found that stigma might play an important role in suicidal ideation (10, 13). For example, a recent meta-analysis showed that HIV-infected patients who reported suicidal ideation were 1.83 (95%CI:1.24, 2.41) times more likely to report HIV-related stigma (10). The non-significant results in our study may be due to the limited sample size and the heterogeneity among participants, including rural and urban locations and varied cultural backgrounds.

Our study found that mental stress, specifically anxiety and depression, were associated with decreased quality of life of HIV-infected patients. Similar results were also found in previous studies (13, 37–39). For example, a cross-sectional study of 184 HIV-infected men who have sex with men showed that anxiety (OR = 2.7, 95%CI: 1.2, 6.1) and depression (OR = 2.6, 95%CI:1.1, 5.9) symptoms were all significantly associated with quality of life (39). A longitudinal study of 200 HIV-infected pregnant women in Tanzania found that higher anxiety and depression levels were associated with decreased quality of life (40). One reasonable explanation is that mental stress always co-exists with chronic medical conditions, treatment resistance and worse psychiatric outcomes, which may decrease quality of life among HIV-infected patients (39, 41).

While no significant direct effect was observed in this study, the SEM analysis found that stigma had a crucial indirect effect on quality of life by increasing the levels of mental stress among HIV-infected women. Several studies have also indicated that HIV-related stigma is one of the most important risks to quality of life among HIV-infected patients (13, 42–43). Several possible explanations might be noted. Firstly, HIV-related stigma can contribute to feelings of social isolation, subsequently exacerbates anxiety and depression symptoms, resulting in reduced quality of life (13, 36). Secondly, stigma might affect the self-esteem and social support of HIV-infected patients, accelerate anxiety and depression symptoms, and ultimately decrease quality of life (13). Overall, our study demonstrated that HIV-related stigma played a very critical role in mental stress and quality of life, and mental stress mediated in part the association between stigma and quality of life. As the duration of HIV infection increases, patients may have an increased understanding of the severity, high infectivity and the fact that there is no cure for AIDS, so they may feel less stressed and less worried about the disease. Different causes of infection also affect the psychological quality of life of patients. For example, an infection through blood donation may affect the patient’s perception of society, resulting in psychological disorders, and affecting the patient’s quality of life.

The greatest strength of this study is the two-stage statistical analysis we applied. Briefly, using GLM analysis we first examined the association between stigma and mental stress (anxiety and depression) or quality of life, and the association between mental stress and quality of life. Associations between stigma, mental stress (anxiety and depression) and quality of life were then explored using a SEM analysis. The results of GLM and SEM were consistent, indicating that they were robust. However, the study has several limitations. First, participants were recruited from two anti-AIDS virus treatment points in Xinjiang province of China. Further studies with more regions and a larger sample size are required to confirm our results. Second, stigma, mental stress, quality of life and other covariables were investigated using a self-administered questionnaire, with the possibility of reporting bias. However, the fact that the questionnaire was anonymous may have minimized this source of bias. Thirdly, quality of life was assessed using a 31-item questionnaire, but a more scientific measure such as the Columbia quality of life scale could provide a more comprehensive understanding of life among HIV-infected patients (44). Finally, the cross-sectional study design does not allow investigation of causal relationships between stigma, mental stress and quality of life. Longitudinal studies, such as cohort studies, are expected to confirm our findings in future.

This study shows that higher levels of stigma are associated with increased risk of mental stress (anxiety and depression) and decreased quality of life. Although no direct effect was found, significant indirect effects were observed in the relationship between stigma and quality of life mediated by mental stress (anxiety and depression). The results of this study provide theoretical and clinical evidence as a basis for psychological intervention in AIDS patients. Reasonable stress reduction measures should be taken to reduce mental strain in AIDS patients, improve their psychological state, and simultaneously enhance societal understanding of AIDS, its mode of transmission and its harms, reduce discrimination toward this special group, and improve their care. These outcomes would increase their social capital, which may contribute to improving the mental health and quality of life of HIV-infected women.

1. Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

2. Author Contributions

All authors participated in the entire research process. First author Feng Ying led the research and writing, Xia Yan and Guo Rui were responsible for data collection, Li Yuefei and He Qian were responsible for data sorting and statistical analysis, and the corresponding author is responsible for reviewing this article and proofreading.

3. Funding

This project ("Research on the mediating Effect of Influencing Factors of Poor Mental Health Outcomes among Women of reproductive age infected with HIV Based on the Perception of Discrimination and Other Perspectives") is supported by the Natural Science Foundation at the Department of Science and Technology of Xinjiang (grant number 2022D01A30). The study was also supported by Xinjiang AIDS prevention and Control Research Key Laboratory (No. XJYS1706-2021002).

4. Acknowledgments

We thank all the AIDS patients and researchers who contributed to this study and the Department of Science and Technology of Xinjiang.

5. Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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No competing interests reported.

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Stigma associated with mental stress and reduced quality of life among HIV-infected women in western China:a cross-sectional study

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Abstract

Figures

1. Introduction

2. Materials And Methods

2.1 Study population

2.2 Method of recruitment

2.3 Stigma, Mental stress and Quality of life assessment

2.4 Covariates

2.5 Statistical analysis

3. Results

3.1 Descriptive statistics

3.2 Associations between stigma and mental stress or quality of life

3.3 Associations between psychological status and quality of life

3.4 Structural equation model analysis of stigma, mental stress and quality of life.

4. Discussion

5. Conclusion

Declarations

1. Conflict of Interest

2. Author Contributions

3. Funding

4. Acknowledgments

5. Data availability

References

Additional Declarations

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