3.1 Demographic characteristics
Among the 1541 people who finished the survey questions, 1297 questionnaires were enrolled in the data analysis. As illustrated in Table 1, over half of the participants were male (n=563, 56.6%) and were less than or equal to 60 years old (n=683, 52.7%). The majority of the participants were from urban areas (n=1136, 87.6%) and married (n=1105, 85.2%). Most of the participants had an income for 2020 less than 60000 CNY (n=805, 62.1%), and had an education level as senior high school or below (n=921, 71%). A small percentage of participants lived alone (n=158, 12.2%), used alcohol no less than 2 times per week (n=117, 9%), and were current smokers (n=161, 12.4%). The COVID-19 patients were clinically classified into four categories: asymptomatic (n=60, 4.6%), mild (n=927, 71.5%), moderate (n=132, 10.2%), critically severe (n=178, 13.7%). A significant proportion of the participants had no experience at ICU (n=1250, 96.4%), had never received psychological or emotional counseling during hospitalization (n=1225, 94.4%), and had never received psychological or emotional counseling before infection (n=1169, 90.1%). Just under a half of participants stayed over 20 days in hospital (n=611, 47.1%), and had no complication (n=530, 40.9%). Most of the patients perceived good (n=736, 56.7%) or moderate (n=247, 19%) mental health status during hospitalization.
Table 1 Demographic characteristics of the participants
Variable
|
N
|
%
|
Gender
|
|
|
Male
|
563
|
43.4
|
Female
|
734
|
56.6
|
Age (years)
|
|
|
≤60
|
683
|
52.7
|
>60
|
614
|
47.3
|
Region
|
|
|
Urban
|
1136
|
87.6
|
Rural areas
|
161
|
12.4
|
Marital status
|
|
|
Unmarried/divorced /widowed
|
192
|
14.8
|
Married
|
1105
|
85.2
|
Income for 2020 (CNY)
|
|
|
<60000
|
805
|
62.1
|
≥60000
|
492
|
37.9
|
Dwelling state
|
|
|
Living alone
|
158
|
12.2
|
Living with others
|
1139
|
87.8
|
Education level
|
|
|
Senior high school or below
|
921
|
71
|
Above senior high school
|
376
|
29
|
Frequency of alcohol use per week
|
|
|
< 2
|
1180
|
91
|
≥2
|
117
|
9
|
Current smoker
|
|
|
No
|
1136
|
87.6
|
Yes
|
161
|
12.4
|
Clinical classification of COVID-19 patients
|
|
Asymptomatic
|
60
|
4.6
|
Mild
|
927
|
71.5
|
Moderate
|
132
|
10.2
|
Critically severe
|
178
|
13.7
|
Experience at ICU
|
|
|
No
|
1250
|
96.4
|
Yes
|
47
|
3.6
|
Length of hospital stay(days)
|
|
|
≤20
|
686
|
52.9
|
>20
|
611
|
47.1
|
Complication
|
|
|
No
|
530
|
40.9
|
Yes
|
767
|
59.1
|
Having received psychological or emotional counseling during hospitalization
|
No
|
1225
|
94.4
|
Yes
|
72
|
5.6
|
Perceived mental health status during hospitalization
|
|
Poor
|
314
|
24.2
|
Moderate
|
247
|
19
|
Good
|
736
|
56.7
|
Having received psychological or emotional counseling before infection
|
|
No
|
1169
|
90.1
|
Yes
|
128
|
9.9
|
3.2 Stigma and related psychological factors
The 12-item CSS-S’s total scores range from 12 to 48 with higher scores indicating a more stigmatizing attitude. The mean score in this study was 28.04 (SD=7.33). The mean scores of fatigue, peace of mind, resilience, and social support were 6.38 (SD=4.04), 24.70 (SD=5.99), 56.82 (SD=14.04), 14.25 (SD=5.18), respectively. The prevalence of PTSD, anxiety, depression, and sleep disorder were 16.5%, 28.8%, 37.9%, and 47.1% respectively.
Table 2 Descriptive statistics for CSS-S, FS-14, PoM, RSQ, Social support, IES-R, GAD-7, PHQ-9 and PSQI
Variable
|
n
|
%
|
Mean (SD)
|
Range
|
Stigma (CSS-S)
|
|
Total score
|
|
|
28.04(7.33)
|
12-48
|
Fatigue (FS-14)
|
|
|
|
Total score
|
|
|
6.38(4.04)
|
0-14
|
Peace of mind (PoM)
|
|
|
Total score
|
|
|
24.70(5.99)
|
7-35
|
Resilience (RSQ)
|
|
|
|
Total score
|
|
|
56.82(14.04)
|
16-80
|
Social support
|
|
|
|
Total score
|
|
|
14.25(5.18)
|
0-20
|
Post-traumatic stress disorder (IES-R)
|
|
|
No
|
1083
|
83.5
|
|
|
Yes
|
214
|
16.5
|
|
|
Anxiety (GAD-7)
|
|
|
|
|
No
|
923
|
71.2
|
|
|
Yes
|
374
|
28.8
|
|
|
Depression (PHQ-9)
|
|
|
|
|
No
|
805
|
62.1
|
|
|
Yes
|
492
|
37.9
|
|
|
Sleep disorder (PSQI)
|
|
|
|
No
|
686
|
52.9
|
|
|
Yes
|
611
|
47.1
|
|
|
Note: CSS-S: COVID-19 Stigma Scale; FS-14: Fatigue Scale-14; PoM: Peace of Mind Scale; RSQ: Resilience Style Questionnaire; IES-R: Impact of Events Scale-Revised; GAD-7: Generalized Anxiety Disorder Questionnaire; PHQ-9: Patient Health Questionnaire; PSQI: Pittsburgh Sleep Quality Index
3.3 Latent profile analysis
Latent profile models (LPA) with one-to-five-class solutions were specified, and the fit indices of the 5 models are displayed in table 3. The entropies of all classifications were above 0.9. The LMR and BLRT test were all statistically significant. The AIC, BIC and aBIC decreased with the increase of class number, and the scree plot of aBIC flattened out after the 3-class model, see figure 1. Taken together, considering the model fit, parsimoniousness, and interpretability of the classes, the 3-class model was selected as the optimal model for the current sample, the distribution and conditional means of items of CSS-S on each class in the 3-class model are illustrated in figure 2 and table 4. In the 3-class model, the average latent class probabilities for most likely latent class membership (0.978, 0.977, 0.972) demonstrate reasonable classification and good distinction, see table 5. Given the conditional means of items on each class, we define Class1 (n=166, 12.8%) as “low perceived COVID-19 stigma” group, Class2 (n=663, 51.1%) as “moderate perceived COVID-19 stigma” group group, and Class3 (n=468, 36.1%) as “severe perceived COVID-19 stigma”.
Table 3 Model fit indices for latent profile models with different classes
Class number
|
AIC
|
BIC
|
aBIC
|
Entropy
|
LMR
|
BLRT
|
Class membership probability
|
1
|
37121.342
|
37245.37
|
37169.134
|
|
|
|
1
|
2
|
31403.104
|
31594.313
|
31476.782
|
0.928
|
<0.001
|
<0.001
|
0.510/0.490
|
3
|
28949.821
|
29208.211
|
29049.386
|
0.944
|
<0.001
|
<0.001
|
0.128/0.361/0.511
|
4
|
27896.009
|
28221.581
|
28021.461
|
0.954
|
0.007
|
<0.001
|
0.125/0.369/0.469/0.037
|
5
|
26872.931
|
27265.684
|
27024.269
|
0.954
|
0.006
|
<0.001
|
0.137/0.360/0.307/0.160/0.036
|
Table 4 Conditional means of items of CSS-S on each class
|
Class1
|
Class2
|
Class3
|
STIGMA1
|
1.597
|
2.433
|
3.022
|
STIGMA2
|
1.188
|
2.097
|
2.744
|
STIGMA3
|
1.174
|
2.035
|
2.742
|
STIGMA4
|
1.463
|
2.387
|
3.074
|
STIGMA5
|
1.343
|
2.222
|
2.921
|
STIGMA6
|
1.428
|
2.394
|
2.956
|
STIGMA7
|
1.239
|
2.249
|
3.144
|
STIGMA8
|
1.183
|
2.05
|
2.981
|
STIGMA9
|
1.299
|
2.277
|
3.129
|
STIGMA10
|
1.084
|
1.948
|
2.934
|
STIGMA11
|
1.087
|
1.986
|
2.952
|
STIGMA12
|
1.108
|
1.907
|
2.877
|
Class membership probability
|
0.128
|
0.511
|
0.361
|
Table 5 Average latent class probabilities for most likely latent class membership by latent class
Latent class
|
Latent class membership
|
1 (166)
|
2 (663)
|
3 (468)
|
1
|
0.978
|
0.022
|
0.000
|
2
|
0.008
|
0.972
|
0.021
|
3
|
0.000
|
0.023
|
0.977
|
3.4 Influencing factors of perceived COVID-19 stigma of RD
The result of univariate analysis showed that female (c2=21.999, P<0.001), older age (c2=45.595, P<0.001), being married (c2=4.401, P=0.111), low family income (c2=23.261, P<0.001), living with other people (c2=7.456, P=0.024), low education level (c2=61.653, P<0.001), having complication (c2=10.117, P=0.006), perceiving worse mental health status during hospitalization (c2=48.489, P<0.001), PTSD (c2=73.360, P<0.001), anxiety (c2=74.878, P<0.001), depression (c2=70.081, P<0.001), sleep disorder (c2=70.875, P<0.001), and fatigue (F=21.220, P<0.001) were positively associated with perceived COVID-19 stigma, while resilience (F=22.030, P<0.001), social support (F=25.070, P<0.001), and peace of mind (F=39.130, P<0.001) were negatively associated with perceived COVID-19 stigma among RD, see table 6. These variables were further employed in stepwise multinomial logistic regression analysis with the “low perceived COVID-19 stigma” group as a reference. The result of stepwise multinomial logistic regression analysis showed that older age (AOR=1.753, P=0.004), living with other people (AOR=2.152, P=0.003), anxiety (AOR=2.444, P=0.004), and sleep disorder (AOR=1.921, P=0.002) were positively associated with moderate perceived COVID-19 stigma, while higher educational level (AOR=0.624, P=0.012) was negatively associated with moderate perceived COVID-19 stigma; Female (AOR=1.674, P=0.011), older age (AOR=3.046, P<0.001), living with other people (AOR=2.037, P=0.011), anxiety (AOR=2.813, P=0.001), and sleep disorder (AOR=2.628, P<0.001) were positively associated with severe perceived COVID-19 stigma, while higher educational level (AOR=0.340, P<0.001), social support (AOR=0.953, P=0.021), and peace of mind (AOR=0.951, P=0.008) were negatively associated with severe perceived COVID-19 stigma among RD.
Table 6 Univariate analysis of influencing factors of perceived COVID-19 stigma of RD
Variable
|
Classification of perceived stigma
|
c2/F
|
P
|
Low perceived COVID-19 stigma
|
moderate perceived COVID-19 stigma
|
Severe perceived COVID-19 stigma
|
Gender
|
|
|
|
21.999
|
<0.001
|
Male
|
86
|
313
|
164
|
|
|
Female
|
80
|
350
|
304
|
|
|
Age(years)
|
|
|
|
45.595
|
<0.001
|
≤60
|
116
|
372
|
195
|
|
|
>60
|
50
|
291
|
273
|
|
|
Region
|
|
|
|
1.695
|
0.428
|
Urban
|
147
|
573
|
416
|
|
|
Rural areas
|
19
|
90
|
52
|
|
|
Marital status
|
|
|
|
4.401
|
0.111
|
Unmarried/divorced /widowed
|
33
|
89
|
70
|
|
|
Married
|
133
|
574
|
398
|
|
|
Family income for 2020 (CNY)
|
|
|
23.261
|
<.0001
|
<60000
|
83
|
396
|
326
|
|
|
≥60000
|
83
|
267
|
142
|
|
|
Dwelling state
|
|
|
|
7.456
|
0.024
|
Living alone
|
28
|
66
|
64
|
|
|
Living with other people
|
138
|
597
|
404
|
|
|
Education level
|
|
|
|
61.653
|
<0.001
|
Senior high school or below
|
88
|
446
|
387
|
|
|
Above senior high school
|
78
|
217
|
81
|
|
|
Frequency of alcohol use per week
|
|
|
1.197
|
0.5496
|
<2
|
149
|
600
|
431
|
|
|
≥2
|
17
|
63
|
37
|
|
|
Current smoker
|
|
|
|
2.349
|
0.309
|
No
|
140
|
580
|
416
|
|
|
Yes
|
26
|
83
|
52
|
|
|
Clinical classification of COVID-19 patients
|
|
7.743
|
0.2575
|
Asymptomatic
|
8
|
36
|
16
|
|
|
Mild
|
130
|
464
|
333
|
|
|
Moderate
|
12
|
69
|
51
|
|
|
Critical severe
|
16
|
94
|
68
|
|
|
Experience at ICU
|
|
|
0.956
|
0.6202
|
No
|
162
|
639
|
449
|
|
|
Yes
|
4
|
24
|
19
|
|
|
Length of hospital stay(days)
|
|
|
0.937
|
0.6259
|
≤20
|
83
|
358
|
245
|
|
|
>20
|
83
|
305
|
223
|
|
|
Complication
|
|
|
|
10.117
|
0.006
|
No
|
86
|
267
|
177
|
|
|
Yes
|
80
|
396
|
291
|
|
|
Having received psychological or emotional counseling during hospitalization
|
0.604
|
0.7396
|
No
|
157
|
629
|
439
|
|
|
Yes
|
9
|
34
|
29
|
|
|
Perceived mental health status during hospitalization
|
|
48.489
|
<0.001
|
Poor
|
22
|
129
|
163
|
|
|
Moderate
|
39
|
129
|
79
|
|
|
Good
|
105
|
405
|
226
|
|
|
Having received psychological or emotional counseling before infection
|
|
0.030
|
0.9852
|
No
|
149
|
598
|
422
|
|
|
Yes
|
17
|
65
|
46
|
|
|
PTSD
|
|
|
|
73.360
|
<0.001
|
No
|
157
|
589
|
337
|
|
|
Yes
|
9
|
74
|
131
|
|
|
Anxiety
|
|
|
|
74.878
|
<0.001
|
No
|
150
|
501
|
272
|
|
|
Yes
|
16
|
162
|
196
|
|
|
Depression
|
|
|
|
70.081
|
<0.001
|
No
|
138
|
438
|
229
|
|
|
Yes
|
28
|
225
|
239
|
|
|
Sleep disorder
|
|
|
|
70.875
|
<0.001
|
No
|
125
|
376
|
185
|
|
|
Yes
|
41
|
287
|
283
|
|
|
Fatigue
|
5.193±4.137
|
6.050±3.931
|
7.263±3.982
|
21.220
|
<0.001
|
Resilience
|
58.693±19.189
|
58.750±12.896
|
53.436±12.772
|
22.030
|
<0.001
|
Social support
|
15.223±5.401
|
14.944±4.761
|
12.928±5.399
|
25.070
|
<0.001
|
Peace of mind
|
26.530±6.807
|
25.558±5.698
|
22.846±5.614
|
39.130
|
<0.001
|
Table 7 Multinomial logistic regression analysis of influencing factors of perceived COVID-19 stigma of RD
Variable
|
Moderate perceived stigma
|
Severe perceived stigma
|
AOR
|
95%CI
|
P
|
AOR
|
95%CI
|
P
|
LL
|
UL
|
LL
|
UL
|
Gender
|
|
|
|
|
|
|
|
|
Male
|
1
|
|
|
|
1
|
|
|
|
Female
|
1.063
|
0.744
|
1.519
|
0.736
|
1.674
|
1.128
|
2.483
|
0.011
|
Age(years)
|
|
|
|
|
|
|
|
|
≤60
|
1
|
|
|
|
1
|
|
|
|
>60
|
1.753
|
1.192
|
2.577
|
0.004
|
3.046
|
2.009
|
4.618
|
<0.001
|
Dwelling state
|
|
|
|
|
|
|
|
|
Living alone
|
1
|
|
|
|
1
|
|
|
|
Living with other people
|
2.152
|
1.304
|
3.553
|
0.003
|
2.037
|
1.181
|
3.515
|
0.011
|
Education level
|
|
|
|
|
|
|
|
|
Senior high school or below
|
1
|
|
|
|
1
|
|
|
|
Above senior high school
|
0.624
|
0.432
|
0.903
|
0.012
|
0.340
|
0.221
|
0.522
|
<0.001
|
PTSD
|
|
|
|
|
|
|
|
|
No
|
1
|
|
|
|
1
|
|
|
|
Yes
|
1.082
|
0.495
|
2.367
|
0.844
|
2.014
|
0.915
|
4.431
|
0.082
|
Anxiety
|
|
|
|
|
|
|
|
|
No
|
1
|
|
|
|
1
|
|
|
|
Yes
|
2.444
|
1.327
|
4.501
|
0.004
|
2.813
|
1.499
|
5.276
|
0.001
|
Sleep disorder
|
|
|
|
|
|
|
|
|
No
|
1
|
|
|
|
1
|
|
|
|
Yes
|
1.921
|
1.275
|
2.895
|
0.002
|
2.628
|
1.695
|
4.072
|
<0.001
|
Social support
|
1.005
|
0.966
|
1.046
|
0.803
|
0.953
|
0.914
|
0.993
|
0.021
|
Peace of mind
|
0.998
|
0.965
|
1.032
|
0.891
|
0.951
|
0.917
|
0.987
|
0.008
|
Note: LL: Lower Limit; UL: Upper Limit
3.5 Receiver Operating Characteristic Analysis
To identify the optimal cut-off value of CSS-S for screening perceived COVID-19 stigma among RD, participants assigned to the “low perceived COVID-19 stigma” group in LPA were defined as “non-cases” (i.e., no stigma), and those assigned in “moderate perceived COVID-19 stigma” and “severe perceived COVID-19 stigma” groups were defined as “cases” (i.e., probable stigma). The ROC curve was then plotted for the total score of CSS-S using the binary outcome, with an AUC value of 99.96% (P<0.001), indicating a good predictive capacity for perceived COVID-19 stigma, see figure 3. The diagnostic criteria and indices are illustrated in table 8. The optimal cut-off value was ≥20, where the sensitivity, specificity, and Youden’s index value were 0.996, 0.982, and 0.978, respectively.
Table 8 Criterion values and coordinates of ROC Curve for perceived COVID-19 stigma
Criterion
|
Sensitivity
|
Specificity
|
Youden’s index
|
≥12
|
1.000
|
0.000
|
0.000
|
>19
|
1.000
|
0.922
|
0.922
|
>20
|
0.996
|
0.982
|
0.978
|
>21
|
0.975
|
1.000
|
0.975
|
>48
|
0.000
|
1.000
|
0.000
|