Factors associated with stigma in adult women with uncomplicated urinary tract infections in China: A cross-sectional study

doi:10.21203/rs.3.rs-3613573/v1

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Research Article

Factors associated with stigma in adult women with uncomplicated urinary tract infections in China: A cross-sectional study

https://doi.org/10.21203/rs.3.rs-3613573/v1

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Background

Uncomplicated urinary tract infections (uUTIs) pose significant risks to women’s physical and mental well-being, with the existence of social stigma further exacerbating the issue. Despite the prevalence and impact of this condition, there is a notable dearth of research exploring the specific stigma associated with uUTIs among women, particularly in regard to the influential factors. The current study seeks to address this gap in the literature, providing evidence of such stigma within the female population in China and identifying the key factors that contribute to its stigma.

Methods

A cross-sectional study was conducted between December 2022 and June 2023, during which samples were collected from 240 adult women with uncomplicated urinary tract infections from various healthcare facilities in Wuxi, China. General information questionnaires, the Chinese Version of the Social Impact Scale (range 24 to 96), the Multidimensional Perceived Social Support Scale, the Self-Rated Anxiety Scale and the Self-Rated Depression Scale were used. The influences associated with disease stigma were analyzed using a series of multiple regression models.

Results

The average stigma score of all participants was 2.71 ± 0.37, indicating a moderate level of shame. Multiple regression analyses revealed significant factors influencing stigma in women with uncomplicated urinary tract infections, including symptom duration, typical uncomplicated urinary tract infections symptoms, frequency of uncomplicated urinary tract infections episodes, disease knowledge, anxiety and depression levels, and social support.

Conclusion

Higher stigma levels in women with uncomplicated urinary tract infections correlated with increased anxiety and depression, reduced social support, frequent uncomplicated urinary tract infections episodes, longer symptom durations, limited disease knowledge, and typical symptoms such as urinary frequency and urgency. These findings stress the necessity of reducing stigma's impact on women's well-being with uncomplicated urinary tract infections.

urinary tract infections

uncomplicated

women

stigma

contributing factors

Urinary tract infections (UTIs) represent one of the most prevalent bacterial infections globally, posing a significant health burden and socioeconomic impact[1]. With an estimated 404.6 million cases worldwide in 2019, UTIs have been a widespread concern[2]. While UTIs can affect both genders, they are particularly prevalent in women [3]. It is estimated that approximately 60% of women will experience UTIs in their lifetime [4] and that 20–40% of women who have had a previous episode are likely to have another, with 25–50% having multiple recurrences [5]. UTIs often recur, but it is important to note that most of these cases are uncomplicated, known as uncomplicated urinary tract infections (uUTIs) [6]. UUTIS in healthy, nonpregnant women who have no signs of urinary tract abnormalities and who present with acute cystitis and pyelonephritis [7]. The global prevalence of uUTIs has drawn attention due to their impact on public health, quality of life, and healthcare costs [8].

Stigma, defined as the experience of being discredited or labeled as different due to a particular characteristic, condition, or identity, has been recognized as a significant psychosocial factor affecting various health conditions [9]. The stigma associated with health conditions can manifest in several ways, including discrimination, social isolation, and reduced utilization of healthcare services [10]. Stigmatized individuals may feel compelled to hide their condition or symptoms to avoid negative social consequences, which can lead to delayed treatment and a diminished quality of life [11].

In recent years, there has been increasing evidence that recurrent uUTIs can have a negative impact on quality of life and mental health [12, 13]. Eriksson et al. conducted a qualitative study in which women with uUTIs described physical and mental health problems, challenges with the illness, limitations in their daily lives, dependence on support, and poor care [14]. Elstad et al.’s qualitative study on symptoms of uUTIs other than urinary incontinence showed that there is indeed stigma attached to symptoms such as urinary frequency and urgency [15].

Despite the considerable impact of uUTIs on women’s health and well-being, little research has focused on the stigma surrounding these infectionss, particularly in the context of uUTIs [16]. China, with its vast and diverse population, presents a unique context in which to study the factors associated with stigma in women with uUTIs. Cultural norms, beliefs, and attitudes regarding health and illness may influence the perception of uUTIs and contribute to stigmatization [17].

Understanding the factors contributing to stigma among adult women with uUTIs is crucial for several reasons. First, acknowledging and addressing the stigma associated with uUTIs can enhance healthcare-seeking behavior and treatment adherence, ultimately improving patient outcomes and reducing the burden on healthcare systems [18]. Second, exploring the factors underlying uUTIs-related stigma can help debunk misconceptions and provide targeted education to the public, dispelling notions that these infectionss are solely caused by poor hygiene or sexual activity [19]. Third, uncovering the sociocultural and psychological determinants of stigma can guide the development of interventions aimed at reducing stigma and its negative consequences [20].

This cross-sectional study seeks to address this research gap by investigating the factors contributing to stigma in adult women diagnosed with uUTIs in China. By identifying these factors, this study aims to inform interventions and strategies that promote a more accurate understanding of uUTIs, mitigate stigma, and improve the overall well-being of women affected by these infectionss.

2.1 Study design and participants

A cross-sectional study was conducted involving a sample of adult women diagnosed with uUTIs in Wuxi, China. Participants were recruited from diverse healthcare settings, including hospitals, clinics, and community health centers. Ethical clearance for this study was obtained from the Research Ethics Committees of Jiangnan University (Approval No. JNU20221201IRB29). Prior to any study procedures, all participants received comprehensive information about the study’s objectives and procedures and provided their informed consent.

A purposive sample of 240 Chinese adult women with uUTIs (To ensure the reliability and validity of the SIS scale, the sample size is typically more than 5–10 times the total number of entries. Therefore, for this study, the sample size was determined to be 240 valid participants, which is 10 times the number of 24 items.) was recruited between December 2022 and June 2023. The inclusion criteria were as follows: (1) age 18 years or older; and (2) clinical diagnosis of uUTIs using internationally recognized guidelines, indicated by symptomatic patients with bacteriuria > 10³ cfu/mL [21]. Symptomatic indicators included urinary frequency, urgency, dysuria, a sensation of incomplete voiding, lower abdominal discomfort, hematuria, and other relevant symptoms; (3) capability to comprehend the study’s procedures and research inquiries accurately. Exclusion criteria encompassed the following: (1) individuals with fever exceeding 38°C; (2) pregnant individuals; (3) those with gynecologic tumors, urolithiasis, genitourinary tract anomalies, those undergoing immunosuppressive therapy, individuals with chronic kidney disease requiring dialysis, and those with chronic urinary retention necessitating urethral catheterization.

2.2 Measurements

In this section, the administered questionnaire and various scales used for data collection are described in detail.

2.2.1 General Information Questionnaire

The General Information Questionnaire covered two main areas: demographic information and disease-related characteristics. Demographic information encompassed age, marital status, childbirth status, menstrual situation, education level, current employment status, health insurance status, and personal monthly income. Disease-related characteristics included details about the nature of uUTIs, such as first or recurrent occurrences, symptoms of uUTIs, duration of typical symptoms, frequency of uUTIs, sexual activity, and vaginal infectious diseases.

2.2.2 Disease Awareness Questions

Disease Awareness Questions The participants were presented with self-administered questions about their knowledge of the disease, rated on a four-point Likert scale[22]. The questions covered common symptoms, causes, preventive measures, and diagnostic and treatment methods related to the disease. Each question’s response ranged from 1 (total ignorance) to 4 (more comprehensive knowledge).

2.2.3 Chinese Version of the Social Impact Scale (SIS)

The Social Impact Scale (SIS) was originally developed by Fife et al. to assess stigma in patients with HIV/AIDS and cancer [23] and was translated by Pan et al. [24]. It consists of four domains (factors): social rejection, financial insecurity, internalized shame, and social isolation. Social rejection pertains to perceived workplace and societal discrimination (9 items), financial insecurity reflects the impact of discrimination on self-perception and relationships (3 items), internalized shame emerges from experiences of rejection and financial insecurity, prompting a desire to conceal the illness (5 items), and social isolation encompasses feelings of loneliness, inferiority, and worthlessness (7 items). Each item is rated on a four-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). Total scores range from 24 to 96, with higher scores indicating greater perceived stigma. The scale’s internal consistency, measured by Cronbach’s coefficients, ranged from 0.85 to 0.9, while interdimensional correlations ranged from 0.28 to 0.66.

2.2.4 Multidimensional Perceived Social Support Scale (MPSSS)

The MPSSS is a 12-item scale assessing perceived social support across three domains: family, friends, and significant others[25]. Each domain comprises four items addressing practical assistance, emotional support, willingness to discuss problems, and aid in decision-making. The scale’s reliability was demonstrated with a Cronbach’s alpha coefficient of 0.89 and an intraclass correlation coefficient (ICC) of 0.92 in this study.

2.2.5 Self-Rated Anxiety Scale (SAS) and Self-Rated Depression Scale (SDS)

The SAS is a psychological tool comprising 20 questions that measure anxiety levels and their changes during treatment [26]. It contains 15 items assessing increasing anxiety levels and 5 items measuring decreasing anxiety. Respondents evaluate the frequency of symptom occurrences using a Likert-4 scale (ranging from 1 for “no” or “very little time” to 4 for “most or all of the time”). The total score is adjusted for standardized scoring. Scores below 50 indicate ‘normal’ levels, 50–59 suggest ‘mild’ anxiety, 60–69 represent ‘moderate’ anxiety, and scores exceeding 70 indicate ‘severe’ anxiety [27]. Previous research has shown satisfactory reliability and internal consistency (Cronbach’s α = 0.66–0.8) [28]. The SDS is a 20-item self-report scale designed to measure depressive states. It consists of ten positively worded and one negatively worded item, with scores ranging from 20 to 80 on a four-point Likert scale [24].

2.3 Statistical Analysis

Descriptive statistics, including measures such as the mean, standard deviation (SD), and frequency, were employed to characterize the sample. The impact of individual characteristics on stigma, as measured by the SIS and its four underlying factors, was assessed using a combination of independent samples t tests, one-way ANOVA tests, and chi-square tests where applicable. For continuous data, Pearson’s r correlation was utilized. In the course of the multiple linear regression analyses, categorical variables underwent conversion into dummy variables for inclusion, whereas continuous numerical variables were directly incorporated. Missing data are skipped and deleted during the data processing mentioned above.

In a subsequent phase, we sought to identify potential predictors of stigma among the characteristics that showed significant associations with stigma. We performed multiple linear regression analyses on the variables that exhibited significance (p < 0.05) in the univariate analyses. These analyses aimed to establish which variables were independently linked to higher stigma scores. The significance threshold for all tests in the regression models was set at 0.05.

3.1 Demographic and clinical factors associated with SIS scores in female patients with uUTIs

Table 1 displays the comparison of average SIS scores among women with uUTIs who had different characteristics. A total of 240 females with uUTIs participated in the survey and were included in the study. The mean age of all participants was 51.58 ± 18.28, ranging from 18 to 92 years. The majority of participants were over the age of 45 (66.25%), had health insurance (66.67%), reported a personal monthly income of less than 5,000 RMB (62.92%), were experiencing menopause (58.75%), were married (88.33%), and had given birth to a child or children (70.83%). Furthermore, most patients had vaginal infections (58.75%), and half of the participants reported engaging in sexual intercourse in the week before the onset of uUTIs. Approximately 22.50% of the patients reported their first uUTIs, while 53.33% had recurrent UTI. Only a small percentage of participants were knowledgeable about common symptoms, causes, prevention, diagnosis, and treatment of the disease (13.34%). Typical symptoms lasted for less than 3 days in 30.41% of patients, and 8.33% reported having a spouse or sexual partner who also had uUTIs. Regarding the stigma scores in Table 1, it is worth noting that nearly all trait scores fall within the range of 2.00 to 2.99, indicating a medium level of stigma [29].

Table 1

Demographic and clinical factors associated with SIS scores in female patients with uUTIs (n = 240).
Variables	Sort	n (%)	SIS (M ± SD)	Statistical value (F/t)	P-value
Age	20–45 years	81 (33.75%)	2.64 ± 0.40	2.738^a	0.067
	45–65 years	97 (40.42%)	2.77 ± 0.31
	65 years and older	62 (25.83%)	2.69 ± 0.34
Education	Elementary and below	75(31.25%)	2.91 ± 0.26	21.208^a	< 0.001
	Junior middle school	57(23.75%)	2.75 ± 0.29
	Senior Middle School	33(13.75%)	2.55 ± 0.28
	Junior college and above	75(31.25%)	2.53 ± 0.38
Health insurance	Yes	160 (66.67%)	2.68 ± 0 .35	-1.250^b	0.213
Health insurance	No	80 (33.33%)	2.74 ± 0.35	-1.250^b	0.213
Personal monthly income	< 5,000 RMB	151 (62.92%)	2.80 ± 0.30	16.619^a	< 0.001
	5,000–10,000 RMB	58 (24.17%)	2.58 ± 0.39
	> 10,000 RMB	31 (12.91%)	2.49 ± 0.36
Menstrual situation	Normal	99 (41.25%)	2.64 ± 0.38	-2.255^b	0.025
Menstrual situation	Postmenopausal	141 (58.75%)	2.75 ± 0.32	-2.255^b	0.025
Marital status	Married	212 (88.33%)	2.70 ± 0.34	-0.578^b	0.558
Marital status	Unmarried/Divorced/Bereaved	28 (11.67%)	2.74 ± 0.41	-0.578^b	0.558
Childbirth situation	Yes	170 (70.83%)	2.72 ± 0.33	1.117^b	0.266
Childbirth situation	No	70 (29.17%)	2.66 ± 0.41	1.117^b	0.266
Uncomplicated UTIs frequency (every year)	First	54 (22.50%)	2.59 ± 0.36	54.705^a	< 0.001
	< 3 times	58 (24.17%)	2.52 ± 0.30
	3–9 times	59 (24.58%)	2.67 ± 0.21
	9–12 times	37 (15.42%)	2.91 ± 0.14
	> 12 times	32 (13.33%)	3.21 ± 0.09
sexual activity	Yes	120 (50.00%)	2.71 ± 0.34	0.900^b	0.921
sexual activity	No	120 (50.00%)	2.70 ± 0.37	0.900^b	0.921
Vaginal infectious	Yes	141 (58.75%)	2.85 ± 0.26	8.140^b	< 0.001
Vaginal infectious	No	99 (41.25%)	2.50 ± 0.36	8.140^b	< 0.001
Typical duration of symptoms	< 3 days	73 (30.41%)	2.50 ± 0.35	22.998^a	< 0.001
	3–7 days	88 (36.67%)	2.68 ± 0.29
	7–14 days	39 (16.25%)	2.87 ± 0.25
	> 14 days	40 (16.67%)	2.96 ± 0.34
Spouse/partner with UTIs	Yes	20 (8.33%)	2.69 ± 0.46	-0.250^b	0.805
Spouse/partner with UTIs	No	190 (79.17%)	2.71 ± 0.34	-0.250^b	0.805
Level of knowledge of disease	Total ignorance	125 (52.08%)	2.82 ± 0.29	14.315^a	< 0.001
	Little knowledge	83 (34.58%)	2.64 ± 0.31
	Some knowledge	23 (9.58%)	2.40 ± 0.48
	More comprehensive knowledge	9 (3.76%)	2.47 ± 0.45
Footnotes:
(a) Abbreviation: uUTIs, uncomplicated urinary tract infections.
(b) In statistical terms, ‘^a’ corresponds to “F,” whereas ‘^b’ corresponds to “t”.
(c) Sexual activity was defined as having engaged in sexual intercourse within the past week.
(d) Vaginitis is an infection caused by pathogenic microorganisms and is diagnosed by clinicians.
(e) Among the thirty patients in the "Spouse/partner with UTIs" group, none had spouses or sexual partners.
(f) We utilized descriptive statistics, t-tests, and one-way ANOVA for our analysis.

We observed varying mean scores across different age groups, although these differences were not statistically significant. However, education level had a significant impact, with lower levels of education associated with higher SIS scores (p < 0.05). Interestingly, factors such as health insurance and marital status did not show a significant impact on SIS scores (p > 0.05). Lower monthly income was linked to higher SIS scores (p < 0.001), indicating a noteworthy relationship between income and stigma. Postmenopausal patients also exhibited higher SIS scores (p < 0.05), suggesting that menopausal status had some influence on stigma perception. Furthermore, the frequency of uUTIs, duration of symptoms, and presence of vaginal infections were significantly associated with higher SIS scores (p < 0.001). On the other hand, factors such as sexual activity and childbirth history did not have significant effects on SIS scores. Notably, greater knowledge about the disease was associated with slightly lower stigma scores (p < 0.001).

3.2 Levels of stigma, psychological measures, and social support in female patients with uUTIs.

Table 2 shows levels of stigma and scores for social support, anxiety and depression in female patients with uUTIs. The mean score of 240 patients' stigma was 64.91 ± 8.44, and the mean score of the entries was 2.71 ± 0.37, which belonged to the middle level of shame. The mean score of 1.00ཞ1.99 is low level, 2.00ཞ2.99 is medium level, and 3.00ཞ4.00 is high level, and the higher the score is, the higher the level of patients' sense of shame is [29]. The mean score of social rejection was 2.49 ± 0.48; the mean score of financial insecurity was 3.03 ± 0.67; the mean score of internalized shame was 3.64 ± 0.39; and the mean score of social isolation was 2.18 ± 0.48, with the highest score of internalized shame and the lowest score of social isolation. The SAS score was 54.31 ± 10.02, the SDS score was 45.36 ± 10.12 and the MPSSS score was 62.12 ± 10.31.

Table 2

Levels of stigma, psychological measures, and social support in female patients with uUTIs.
Scales and dimensions	Number of scales	Patient score (M ± SD)	Scales score (M ± SD)
SIS	24	64.91 ± 8.44	2.70 ± 0.35
Social rejection	9	22.39 ± 4.33	2.49 ± 0.48
Financial insecurity	3	9.10 ± 2.00	3.03 ± 0.67
Internalized shame	5	18.19 ± 1.93	3.64 ± 0.39
Social isolation	7	15.24 ± 3.35	2.18 ± 0.48
SAS	20	54.31 ± 10.02
SDS	20	45.36 ± 10.12
MPSSS	12	62.12 ± 10.31
Footnotes:
(a) Abbreviation: SIS, Stigma Impact Scale; SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale; MPSSS, Multidimensional Scale of Perceived Social Support.
(b) Mean scores are presented as M ± SD. Social rejection, financial insecurity, internalized shame and social isolation are the four dimensions of SIS.
(c) Descriptive statistics were applied.

3.3 Comparisons of uUTIs symptoms across varying stigma levels.

Table 3 presents a comprehensive comparative analysis of uUTIs symptoms across varying levels of stigma. The table highlights the distinct distribution of symptoms among individuals with low, medium, and high levels of stigma, demonstrating statistically significant differences (p < 0.001).

Table 3

Comparisons of uUTIs symptoms across varying stigma levels.
Variables	Low level (n/%)	Medium level (n/%)	High level (n/%)	χ²	P-value
Urinary frequency	2 (1.05%)	141 (73.82%)	48 (25.13%)	46.274	< 0.001
Urgency	3 (1.69%)	128 (72.32%)	46 (25.99%)
Dysuria	5 (2.99%)	118 (70.66%)	44 (26.35%)
Hematuria	1 (1.14%)	38 (43.18%)	49 (55.68%)
Sense of incomplete emptying	1 (4.00%)	24 (96.00%)	0 (0.00%)
Footnotes: A chi-square test was utilized. The mean score of 1.00ཞ1.99 is low level, 2.00ཞ2.99 is medium level, and 3.00ཞ4.00 is high level, and the higher the score is, the higher the level of patients' sense of shame is(Qin et al., 2018).
Qin, H., Tang, D., Shi, H., Zhou, J., & Chen, Y. (2018). The level and factors associated with stigma in stroke patients with dysphagia. Journal of Nursing Science, 33(9), 15–17. http://doi.org/10.3870/j.issn.1001-4152

3.4 Correlation matrix of components in female patients with uUTIs.

The correlation matrix revealed the associations of patients’ disease stigma with SAS, SDS, and MPSSS scores. It is positively correlated with SAS (p < 0.001) and SDS (p < 0.001) and negatively correlated with MPSSS (p < 0.001). The SIS encompasses four domains: social rejection, financial insecurity, internalized shame, and social isolation. All dimensions have significant positive correlations with anxiety and depression (p < 0.05) and significant negative correlations with perceived social support (p < 0.001; Table 4).

Table 4

Correlation matrix of components in female patients with uUTIs (n = 240).
Components	1	2	3	4	5	6	7	8
1.SIS total	1
2.Social Rejection	0.862**	1
3.Financial Insecurity	0.437**	0.163*	1
4.Internalized Shame	0.584**	0.346**	0.208**	1
5.Social Isolation	0.812**	0.585**	0.175**	0.326**	1
6.SAS	0.425**	0.384**	0.121	0.178**	0.402**	1
7.SDS	0.535**	0.473**	0.171**	0.183**	0.532**	0.585**	1
8.MPSSS	-0.425**	-0.310**	-0.290**	-0.229**	-0.367**	-0.227**	-0.340**	1
Footnote: p < 0.05; p < 0.01; **p < 0.001.

3.5 Multivariate regression modeling for the predictors of stigma in female patients with uUTIs.

Table 5 demonstrates the results of the multiple regression model for the total SIS. In this multiple regression model, the factors that were significantly associated with the total SIS were considered potential predictors. From the results of the calculations in Table 5, it can be concluded that the model fit is good, with an adjusted R-squared of 0.741, which means that the independent variables involved in this regression analysis have a 74.1% effect on the dependent variable (namely, 74.1% of the change in the dependent variable is due to the above independent variables). In other words, the present regression model is able to better explore the factors influencing the stigma of uUTIs in women. The linear regression model in this study was significant (F = 27.243, p < 0.01), which means that at least one of the above independent variables significantly affects women's stigma toward uUTIs.

Table 5

Multivariate regression modeling for the predictors of stigma in female patients with uUTIs (n = 240).
	Variables		Unstandardized coefficient		Standardized coefficient	t-value	P-value	VIF
	Variables		B	Std. Error	Beta	t-value	P-value	VIF
		Constant	2.115	0.165		12.838	< 0.001
Control Variable		Age	-0.003	0.001	-0.131	-2.007	0.046	3.907
	Education	Junior middle school	-0.009	0.036	-0.011	-0.248	0.805	1.787
		Senior Middle School	-0.011	0.047	-0.011	-0.241	0.81	1.92
		Junior college and above	-0.082	0.053	-0.108	-1.551	0.122	4.446
		Elementary and below	0
	Personal monthly income	5,000–10,000 RMB	-0.023	0.035	-0.029	-0.666	0.506	1.695
		> 10,000 RMB	0.026	0.049	0.025	0.539	0.59	1.988
		< 5,000 RMB	0
	Menstrual situation	Postmenopausal	0.013	0.044	0.018	0.286	0.775	3.482
	Menstrual situation	Normal	0
	Vaginal infectious	Yes	0.147	0.027	0.206	5.445	< 0.001	1.321
	Vaginal infectious	No	0
Independent Variable	Typical symptoms of uncomplicated UTIs	Urinary frequency	0.102	0.036	0.117	2.858	0.005	1.535
		Urgency	0.082	0.037	0.103	2.249	0.026	1.934
		Dysuria	-0.02	0.029	-0.026	-0.677	0.499	1.323
		Hematuria	0.078	0.03	0.1	2.62	0.009	1.344
		Sense of incomplete emptying	0.029	0.031	0.033	0.941	0.348	1.132
	Uncomplicated UTIs frequency (every year)	< 3 times	0.025	0.038	0.031	0.678	0.499	1.936
		3–9 times	0.076	0.039	0.094	1.959	0.051	2.114
		9–12 times	0.232	0.045	0.239	5.184	< 0.001	1.95
		> 12 times	0.369	0.056	0.358	6.547	< 0.001	2.75
		First episode	0
	Typical duration of symptoms	3–7 days	0.067	0.031	0.092	2.171	0.031	1.669
		7–14 days	0.077	0.041	0.081	1.866	0.063	1.718
		> 14 days	0.094	0.046	0.1	2.055	0.041	2.174
		< 3 days	0
	Level of knowledge of disease	Total ignorance	0.14	0.069	0.199	2.027	0.044	8.863
		Little knowledge	0.076	0.068	0.102	1.111	0.268	7.827
		Some knowledge	-0.06	0.073	-0.05	-0.813	0.417	3.496
		More comprehensive knowledge	0
		SAS	0.004	0.002	0.125	2.89	0.004	1.726
		SDS	0.004	0.002	0.125	2.748	0.007	1.91
		MPSSS	-0.003	0.001	-0.09	-2.332	0.021	1.368
R square						0.769
Adjusted R square						0.741
F value						27.243
P value						< 0.001
Footnotes:
(a) The variables “Elementary and below,”“<5, 000 RMB,” “no infectious diseases of the vagina,” “first,”“ <3 days,” and “more comprehensive knowledge” were treated as dummy variables and were excluded from the multiple linear regression analysis.
(b) Coding information: the dummy variable in (a) is coded as 0 and the other variables in the same subgroup are coded as 1. For example, in the education group, the dummy variable “Elementary and below,” is coded as 0 and the other variables “Junior Middle School,” “Senior Middle School,” “Junior College and above” are coded as 1. Other subgroups were coded as in the above example.
(c) Multiple linear regression analysis was conducted, with the total SIS considered as the dependent variable and the statistically significant variables from Table 1 included as the independent variables in the regression analysis.

In Table 5, our research findings revealed that age, education level, personal monthly income, and menstrual situation did not exhibit any significant associations with SIS levels. However, the presence of a vaginal infections correlated with elevated SIS scores. Among the common symptoms of uUTIs, such as urinary frequency, urgency, and hematuria, positive connections were observed with SIS scores (p < 0.05). Furthermore, an increase in the annual frequency of uUTIs corresponded to higher SIS scores (p < 0.05). Distinct patterns were observed when considering the duration of symptoms within different subgroups. Specifically, symptom durations of 3–7 days and > 14 days exhibited positive associations with higher SIS scores (p < 0.05). Conversely, the subgroup experiencing symptoms for 7–14 days did not show any significant association with SIS levels (p > 0.05). The level of disease knowledge displayed a variable impact on SIS scores. A complete lack of knowledge demonstrated positive coefficients (p < 0.05), whereas higher levels of knowledge, including limited, moderate, and comprehensive knowledge, displayed no notable correlations with SIS scores (p > 0.05). Furthermore, psychological factors emerged as influential variables. Elevated scores on both the SAS and SDS were linked to higher SIS scores (p < 0.05). Conversely, a higher score on the MPSSS was associated with lower SIS scores (p < 0.05).

In addition, a diagnostic analysis of collinearity for the above regression model was performed in the supplementary information, where Fig. 1 shows the histogram of residuals for this regression model. The histogram in Fig. 1 is utilized to assess whether the residuals conform to a normal distribution.

Historically, research on the stigma associated with urological conditions has been centered around urinary incontinence, prostatitis, and interstitial cystitis. For instance, Wang et al.[30] highlights how stigma related to stress urinary incontinence deterred a significant number of women aged 40 to 65 from seeking medical treatment. Similarly, Elstad et al.[15] conducted a qualitative study to explore the stigma linked to UTI symptoms, including frequent and urgent urination, while distinguishing it from the discrimination associated with incontinence. Given that symptoms such as urinary frequency, urgency, dysuria, hematuria, and a feeling of incomplete emptying are common in uUTIs, it is clear that individuals with uUTIs can also face stigma. Despite some qualitative research highlighting the adverse emotional effects of uUTIs symptoms and their interference with daily life and relationships [12, 31], there has been a noticeable gap in research specifically focused on the stigma faced by women with uUTIs. However, our study broadens this scope by investigating the stigma encountered by women with uUTIs.

Our study pioneered a cross-sectional analysis of factors influencing uUTIs and the associated stigma in women. Our findings provide a richer understanding of the stigma experienced by adult women with uUTIs in China. In this study, we scrutinized the association between various demographic and clinical factors and stigma levels among female uUTIs patients. We also assessed levels of stigma, psychological measures, and social support within this group, examining the interplay between uUTIs symptoms and stigma levels. Additionally, we conducted correlation and regression analyses to unravel the intricate web of factors influencing stigma levels. One of our key discoveries is the significant connection between elevated stigma levels in women with uUTIs and heightened levels of anxiety and depression. Furthermore, this group reported lower levels of social support, more frequent uUTIs, longer symptom durations, less knowledge about uUTIs, and commonly experienced symptoms such as urinary frequency and urgency.

In our study, a substantial portion of uUTIs patients reported experiencing moderate levels of stigma, aligning closely with stigma levels associated with urinary incontinence, as revealed in Wang et al.’s study [30]. Among the 240 participants examined, the average level of stigma was 45.21 ± 16.68. The stigma scores across the four dimensions were as follows: social rejection at 2.49 ± 0.48, financial insecurity at 3.03 ± 0.67, internalized stigma at 3.64 ± 0.39, and social isolation at 2.18 ± 0.48. Internalized stigma emerged as the highest dimension, whereas social isolation ranked the lowest. The elevated levels of internalized stigma observed in our study could be influenced by traditional Chinese culture, where discussing illnesses related to intimate areas is often considered taboo. Moreover, women frequently attributed uUTIs to lifestyle habits and behaviors, such as poor hygiene, general carelessness, and even the perception of it as a ‘punishment of growing old’ [19]. Recurrent uUTIs and prolonged symptoms can lead to serious financial implications for patients. Symptoms such as urinary frequency and urgency can also affect the patient’s social life, resulting in experiences of social rejection and financial insecurity[32]. Additionally, the established connection between physical health and stigma, as documented by various researchers[33], highlights how uUTIs symptoms can contribute to a sense of stigma among individuals already grappling with health challenges. The symptoms of uUTIs can evoke feelings of embarrassment and shame [15], perpetuate false beliefs and stereotypes, and overshadow an individual’s broader health context. Society frequently associated uUTIs with poor hygiene or promiscuity, leading to unfair judgments and blame directed at individuals already contending with a challenging health issue. This can foster a culture of silence and reluctance to seek help, as individuals fear being labeled or stigmatized[34]. Therefore, it is crucial to approach discussions about uUTIs symptoms with sensitivity and empathy. Acknowledging the potential for stigma associated with these symptoms is essential to creating an inclusive and supportive environment for individuals facing health challenges. Promoting understanding, education, and open dialog is imperative to ensure that everyone feels comfortable seeking the care they need, free from judgment or stigma.

Anxiety, depression, and social support are key factors contributing to stigma. Specifically, anxiety and depression can have a significant positive impact on stigma, and they can also mutually influence each other. The symptoms of uUTIs can evoke feelings of embarrassment and shame [35]. Social support plays a crucial role in mitigating disease-related stigma. Low levels of social support can lead to social isolation and further reinforce disease stigma. Additionally, inadequate social support can also contribute to negative health outcomes and worsen the overall well-being of individuals facing disease-related stigma. The absence of a robust support system can intensify feelings of isolation, making it even more challenging for individuals to cope with the stigma associated with their condition.

This study reveals a moderate level of stigma among Chinese women with uUTIs and identifies associated factors. The significant stigma presence underscores the need for targeted interventions to enhance well-being. Addressing uUTIs-related stigma in China demands a culturally sensitive, comprehensive approach. Education is pivotal, dispelling misconceptions and empowering timely care seeking. Healthcare providers must receive training to offer compassionate, nonjudgmental care to women with uUTIs. Prioritizing hematuria management and symptom relief can ease physical discomfort, potentially reducing stigma.

4.1 Limitations

There are several limitations to our study that should be acknowledged. First, we were limited in the factors we examined and did not control for variables such as self-esteem, self-efficacy, and self-avoidance, which may have influenced our results. Second, the results of our study may be specific to the cultural context of traditional Chinese society, so caution should be exercised in generalizing these findings to other populations. It is important to note that our study only provides a preliminary understanding of the stigma experienced by uUTIs patients, and larger longitudinal studies are needed to gather more comprehensive information in the future. In addition, our study population may not effectively represent certain stigmatized populations due to their reluctance to seek healthcare. Despite these limitations, to the best of our knowledge, this is the first study to assess the factors associated with female uUTIs patients in China, and the findings suggest that Chinese women with uUTIs may experience a sense of stigma.

In China, there is a certain level of stigma among adult women suffering from uUTIs. Factors contributing to this stigma include symptoms such as frequent urination, urgency, and blood in the urine, as well as the frequency and duration of these symptoms. Other factors include the individual’s knowledge of the disease, feelings of anxiety and depression, and the level of social support they receive.

Stigma remains a significant issue for adult women with uUTIs in China, negatively impacting their quality of life. This study identifies factors associated with stigma in women with uUTIs and highlights the importance of improving chronic uUTIs management strategies to reduce stigma through health education. By addressing these factors, healthcare professionals and policy makers can work to reduce stigma and improve the overall health of Chinese women with uUTIs.

UTI: urinary tract infections;

uUTIs: uncomplicated urinary tract infections;

SIS: Social Impact Scale;

MPSSS: Multidimensional Perceived Social Support Scale;

SAS: Self-Rated Anxiety Scale;

SDA: Self-Rated Depression Scale.

Ethics approval and consent to participate

This study was conducted in accordance with the Helsinki Declaration. Ethical clearance for this study was obtained from the Research Ethics Committees of Jiangnan University (Approval No. JNU20221201IRB29). Participants were informed of the aim of the study, the methods used and how they would participate. Prior to being included at the research, informed consent was obtained in writing. Confidentiality of respondents were respected. Participants were informed about the voluntariness of their participation.

Consent for publication

All authors have reviewed the manuscript and have approved the final version for publication.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

Authors declare any financial support or relationships that may pose conflict of interest.

All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and that all authors are in agreement with the manuscript.

Author Contribution

YDW made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data as well as article writing; HYL, PJ, FPL, NHF involved in drafting the manuscript or revising it critically for important intellectual content; ZL, YZ, SYW involved in acquisition and analysis of data; SIF, NZ involved in acquisition of data.

Funding Statement

Projects funded by the National Natural Science Foundation of China (No.82370777).

Acknowledgments

The authors express their gratitude to all the women who participated, as well as the graduate students and hospital nurses who assisted with data collection.

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No competing interests reported.

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Factors associated with stigma in adult women with uncomplicated urinary tract infections in China: A cross-sectional study

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Abstract

Background

Methods

Results

Conclusion

Figures

1. Background

2. Methods

2.1 Study design and participants

2.2 Measurements

2.2.1 General Information Questionnaire

2.2.2 Disease Awareness Questions

2.2.3 Chinese Version of the Social Impact Scale (SIS)

2.2.4 Multidimensional Perceived Social Support Scale (MPSSS)

2.2.5 Self-Rated Anxiety Scale (SAS) and Self-Rated Depression Scale (SDS)

2.3 Statistical Analysis

3. Results

3.1 Demographic and clinical factors associated with SIS scores in female patients with uUTIs

3.2 Levels of stigma, psychological measures, and social support in female patients with uUTIs.

3.3 Comparisons of uUTIs symptoms across varying stigma levels.

3.4 Correlation matrix of components in female patients with uUTIs.

3.5 Multivariate regression modeling for the predictors of stigma in female patients with uUTIs.

4. Discussion

4.1 Limitations

5. Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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