Perceived stress and its psychosocial and clinical correlates among patients with pulmonary tuberculosis: A cross-sectional study

ABSTRACT

Background:

Although various psychosocial consequences of pulmonary tuberculosis (PTB) have been thoroughly evaluated, perceived stress has not been well studied.

Aim:

This study assessed perceived stress and its psychosocial and clinical correlates.

Methods:

An institution-based cross-sectional study was conducted among 410 PTB patients. Data were analyzed by Statistical Package for the Social Sciences (SPSS) v23. Independent sample t-test and Pearson correlation were used to test the association between perceived stress and other variables. Assumptions of linear regression were checked. Multiple regression analysis was done to identify statistically significant association at P < 0.05.

Results:

Anxiety, perceived social support, and stigma were found to have significant association with perceived stress in multiple regression analysis. Perceived social support and duration of treatment were negatively significantly associated with perceived stress. Patients with PTB had high perceived stress, and moderate to strong significant correlation was observed among variables.

Conclusion:

Interventions tailored at addressing various psychosocial aspects of tuberculosis (TB) are needed.

INTRODUCTION

Tuberculosis (TB) has a major impact on the patients’ physical, psychological, and social well-being because patients suffer not only from the symptoms of the disease, but also from the ensuing overall deterioration in quality of life.[1] Various adverse psychosocial consequences such as depression, anxiety, stress, stigma, social isolation, and poor quality of life have been reported previously,[2] and were identified as the negative predictors of life satisfaction in patients with TB.[3] Moreover, perceived stress was observed to have a negative impact on various physiological systems, and individuals with high level of stress might also be at risk of negative emotions, including depression and anxiety.[4]

Previous research showed that considerably high burden of psychosocial problems was reported among patients with pulmonary tuberculosis (PTB), including depression (9.9%–80%),[5,6] anxiety (26%–40%),[6,7] and stigma (18%–47.6%).[7,8]

Given that patients with TB experience various psychosocial consequences, previous studies mainly focused on depression, anxiety, and stigma, and little has been explored about perceived stress. Additionally, the correlation between TB-related psychosocial consequences has not been thoroughly studied. For instance, social support was shown to have a positive relationship with the psychological well-being and to lessen the negative impacts of perceived stress;[9,10] nevertheless, the relationship between perceived stress and social support among patients with PTB has not been investigated. Similarly, in patients with PTB, perceived stress was not specifically evaluated in relation to perceived stigma and anxiety. Therefore, the present study assessed perceived stress and its association with perceived social support, stigma, anxiety, clinical factors, and current substance use among patients with PTB and further evaluated the correlation among these variables.

MATERIALS AND METHODS

In this study, we used data primarily collected for the primary objective of the current study. Hence, details about the setting, participants, sampling, and data collection procedure are presented elsewhere.[11] The diagnosis of TB in this study setting may be reached at by using bacteriologic examination (Xpert MTB/RIF Ultra assay, smear microscopy, culture), imaging techniques (chest X-rays), and histopathology. Additionally, the first-line treatment regimen of 2 months with rifampicin, isoniazid, pyrazinamide, and ethambutol 2 (RHZE)/4 months with isoniazid and rifampicin 4 (RH) was followed for new drug-susceptible TB patients.[12]

The outcome variable was perceived stress. Explanatory variables were sociodemographic variables, perceived social support, perceived stigma, duration of illness, duration of treatment, anxiety, body mass index (BMI), family history of mental illness, human immunodeficiency virus (HIV)-acquired immunodeficiency syndrome (AIDS) and other chronic diseases, and current substance use. Current substance use was recorded when the patients reported to have used khat, tobacco, and alcohol in the recent 3 months. Perceived social support was assessed by the three-item Oslo social support scale.[13] The score ranged from 3 to 14, and a higher score indicated strong perceived social support. This tool had Cronbach α = 0.84 in the current study.

Perceived stress was assessed by the 10-item perceived stress scale (PSS-10).[14] It is a five-point Likert-type scale (scored from 0 = never to 4 = very often), which evaluates the perception of stressful experiences in the past month. The total score ranged from 0 to 40, with a higher score indicating higher perceived stress. PSS-10 was validated in Ethiopia and was reported to have adequate psychometric properties to assess stress.[15] Also, it was found to work well in this study with Cronbach α = 0.80.

Perceived stigma was assessed by the 11-item perceived TB stigma scales, which were adopted from Somma et al.[16] Anxiety was assessed by the anxiety subscale (HAD-A) of the hospital anxiety and depression scale (HADS). The anxiety subscale has seven items, with scores ranging from 0 to 21 and a higher score indicating higher anxiety symptoms.

Data were analyzed by Statistical Package for the Social Sciences (SPSS) v23. Independent sample t-test and Pearson correlation were used to assess the association between variables. Assumptions of normality, linearity, outliers, and homogeneity of variances were checked. Multicollinearity was checked by variance inflation factors (VIFs), and the VIF value of all variables was less than 5. Multiple linear regression models with standardized β and 95% confidence interval (CI) were fitted to identify the statistically significant association at P < 0.05. Ethical clearance was obtained from the Research and Ethics Review Board of Jimma University Institute of Health. Written informed consent was obtained from each participant, and confidentiality of the information taken from the participants was maintained.

RESULTS

Distribution of demographic, clinical, and psychosocial characteristics of the study participants

A total of 410 participants were enrolled in the study, with an overall response rate of 99.03%. The mean age of the respondents was 31.85 (standard deviation [SD] = ±12.42), and the minimum and the maximum age was 18 and 74 years, respectively. More than half of the study participants were Muslims (62.7%), urban residents (52.2%), and had a family size of five or more members (87.3%). Majority (68.0%) reported to have the illness for a duration of less than or equal to a month. The mean HAD-A score was 7.27 (SD = ±3.85). Over half (54.1%) of them reported to be on treatment for about 2 months. Details are presented elsewhere.[11]

Perceived stress and its association with demographic factors, clinical factors, and current substance use

The mean perceived stress score of the study participants was 15.97 (SD = 6.42), where over half (54.3%) of them scored above the mean score. There was a significant difference in the mean stress scores between males and females, with females found to have higher perceived stress than males (t = 3.62, P < 0.001). Significant differences in the mean scores on perceived stress were observed with regards to alcohol use (t = 2.78, P = 0.006), khat use (t = 2.61, P = 0.009), tobacco use (t = 2.15, P = 0.032), HIV coinfection (t = 3.67, P < 0.001), and other chronic diseases (t = 2.27, P = 0.023). Patients with family history of mental illness were observed to have higher perceived stress, which was significantly different from their counterparts (t = 5.56, P < 0.001)

Correlation between perceived stress, perceived stigma, social support, anxiety, and other clinical variables

Perceived stigma (r = 0.481, P < 0.001), anxiety symptoms (r = 0.577, P < 0.001), and duration of illness (r = 0.182, P < 0.001) were significantly positively correlated with perceived stress. Duration of treatment (r = −0.369, P < 0.001), BMI (r = −0.237, P < 0.001), and perceived social support (r = −0.584, P < 0.001) were observed to have a significant negative correlation with perceived stress. Treatment duration was significantly negatively associated with perceived stigma (r = −0.273, P < 0.001) and anxiety (r = −0.408, P < 0.001) [Table 1].

Table 1.

Correlation between psychosocial and clinical variables (n=410)

	1	2	3	4	5	6	7
1. Perceived stigma
2. Social support	−0.436**
3. Illness duration	0.191**	−0.229**
4. BMI	−0.128**	0.239**	−0.304**
5. Anxiety	0.488**	−0.501**	0.299**	−0.361**
6. Perceived stress	0.481**	−0.584**	0.182**	−0.237**	0.577**
7. Treatment duration	−0.273**	0.375**	−0.171**	0.267**	−0.408**	−0.369**

BMI=body mass index. **P<0.01

Multiple regression analysis revealed that perceived social support (β = −0.34, 95% CI: −1.00, −0.59; P < 0.001) was significantly inversely associated with perceived stress. Anxiety symptoms (β = 0.28, 95% CI: 0.31, 0.64; P < 0.001) and perceived stigma (β = 0.16, 95% CI: 0.17, 0.59; P < 0.001) were observed to have significant positive association with perceived stress. Variables in the model explained about 48% variation in perceived stress, where perceived social support was found to have greater contribution followed by anxiety [Table 2].

Table 2.

Multiple linear regression analysis of factors associated with perceived stress (n=410)

Variable	β	95% CI	P	Collinearity diagnosis
			Tolerance	VIF
Sex/female	0.022	−0.724, 1.280	0.586	0.827	1.209
Anxiety	0.285	0.313, 0.636	<0.001	0.539	1.855
Duration of illness	−0.027	−0.303, 0.149	0.505	0.829	1.206
BMI	−0.019	−0.276, 0.173	0.651	0.777	1.287
Treatment duration	−0.068	−0.164, 0.016	0.107	0.747	1.338
Other comorbidity	0.040	−0.962, 3.065	0.305	0.863	1.158
HIV coinfection	−0.014	−1.428, 0.975	0.711	0.869	1.151
Family history of mental illness	0.008	−1.130, 1.378	0.846	0.791	1.264
Current tobacco use	0.009	−1.974, 2.475	0.825	0.827	1.208
Current alcohol	0.059	−0.363, 2.423	0.147	0.804	1.245
Current khat use	0.033	−0.616, 1.463	0.424	0.781	1.281
Social support	−0.337	−1.009, −0.592	<0.001	0.643	1.554
Perceived stigma	0.160	0.171, 0.592	<0.001	0.646	1.549

BMI=body mass index, CI=confidence interval, HIV=human immunodeficiency virus, VIF=variance inflation factor. Other comorbidity: diabetic mellitus, hypertension, epilepsy, asthma

DISCUSSION

The present study assessed perceived stress, its psychosocial and clinical correlates, and the association among these variables. Perceived social support (β = −0.34, P < 0.001) was significantly negatively associated with perceived stress, suggesting that the greater the level of social support perceived by the patients, the lower the perceived stress experienced. The finding is in agreement with evidence from several reports suggesting that social support may protect an individual from the negative impacts of perceived stress and lessen the impact of stress on the physical and psychological well-being.[9,10]

Anxiety (β = 0.28, P < 0.001) was significantly associated with perceived stress. A higher anxiety level was associated with higher score on PSS, and similar finding was documented previously.[17] Furthermore, perceived stigma (β = 0.16, P < 0.001) was observed to have significant positive association with perceived stress. The significant association between perceived stigma and stress may be explained in part by the fact that the feelings of shame or embarrassment that encompass perceived stigma might inhibit individuals’ adaptation to the stressor by sustaining a focus on the negative aspects of the particular stressor.[18]

Duration of treatment was found to have significant negative correlation with perceived stigma and anxiety, indicating that the longer the patients stay on treatment, the lesser are the perceived stigma and anxiety experienced. The finding was supported by previous reports suggesting that patients with TB experience increased anxiety and stigma during the initial phase of treatment, which likely improves over time during the continuation phase.[19,20]

Another important correlation observed in this study was that perceived social support was significantly negatively associated with the duration of illness, anxiety, and perceived stigma, indicating that the greater the social support perceived by the patients, the lower are the duration of illness, anxiety symptoms, and perceived stigma. It is generally understood that social support facilitates health-seeking behavior, which, in turn, lowers the duration of the illness and lessens the delay in diagnosis.

Moreover, the negative association observed between social support and perceived stigma is supported by a previous study.[18] This may be explained in part by the fact that perceived stigma impairs social support. Particularly in the context of a highly stigmatized disease such as PTB, patients may suffer from the shame and fear of being discriminated, which often leads them to withdraw from social interactions.[18]

Even though the study provides valuable insight into the relationship between various psychosocial consequences of TB, some limitations could be noted. Due to the cross-sectional design, it is not possible to ascertain a temporal relationship. Since the study used face-to-face interview, patients might have provided socially desirable response, most notably for substance use. The study was facility based; hence, the finding may not be generalizable to those with similar conditions in the community. Although an attempt was made to include various potential confounders, some important variables may be missed. For instance, depression was not included in the current analysis.

CONCLUSION

The study demonstrated that patients with PTB perceived high stress, which was significantly associated with perceived social support, perceived stigma, and anxiety. Furthermore, significant correlation was observed among the psychosocial and clinical variables. The fact that patients with PTB had high perceived stress and moderate to strong correlation was observed among variables calls up on the interventions tailored at addressing various psychosocial aspects of TB.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.