The Analysis of Stigma Status and Its Impact on Medication Adherence in Patients Undergoing Maintenance Hemodialysis

The Analysis of Stigma Status and Its Impact on Medication Adherence in Patients Undergoing Maintenance Hemodialysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Analysis of Stigma Status and Its Impact on Medication Adherence in Patients Undergoing Maintenance Hemodialysis Shuying Yang, Yitian Cai, Biyi Wen, Yanshan Huang, Wenting Wu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8530420/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Patients undergoing maintenance hemodialysis (MHD) often experience stigma, which may adversely affect their health behaviors. This study aimed to investigate the status of stigma and its impact on medication adherence in this population. Methods A cross-sectional study was conducted using a convenience sample of 132 MHD patients from a tertiary hospital in Guangzhou, China. Participants completed the Chinese versions of the Stigma Scale for Chronic Illness (SSCI) and the Morisky Medication Adherence Scale (MMAS-8), along with a general information questionnaire. Descriptive statistics, t-tests, ANOVA, Pearson correlation, and multiple linear regression were used for data analysis. Results The mean total stigma score was 65.39 ± 11.31, indicating a moderate level. Stigma scores significantly differed across age, education, employment, income, marital status, mobility, dialysis vintage, and presence of complications (all P < 0.05). A significant negative correlation was found between stigma and medication adherence (r = -0.464, P 10 years), presence of complications, and lower medication adherence as significant factors associated with higher stigma (Adjusted R² = 0.489). Conclusion MHD patients experience considerable stigma, which is negatively associated with medication adherence. Healthcare providers should implement comprehensive assessments and targeted psychosocial interventions to mitigate stigma and improve treatment adherence in this vulnerable group. Maintenance hemodialysis Stigma Medication adherence Psychosocial factors Quality of life 1. Introduction End-stage renal disease (ESRD) represents a formidable and escalating global public health burden, with its prevalence projected to rise steadily worldwide [ 1 ]. In China, concurrent with an aging population and increasing rates of diabetes and hypertension, the incidence of ESRD has surged, imposing substantial demands on healthcare systems [ 2 ]. For patients with ESRD, maintenance hemodialysis (MHD) serves as a cornerstone life-sustaining therapy, effectively prolonging survival [ 3 ]. However, the clinical paradigm is progressively shifting from a singular focus on mortality reduction towards a more holistic emphasis on improving patients' long-term quality of life (QoL) and psychosocial well-being [ 4 ]. Patients undergoing MHD constitute a distinct chronic illness population, frequently contending with a profound and detrimental psychosocial experience: stigma. Stigma arises from societal labeling, stereotyping, and discrimination associated with the illness and its demanding treatment regimen [ 5 ]. For MHD patients, sources of stigma are multifactorial, encompassing misconceptions about kidney disease etiology, the intrusive and machine-dependent nature of dialysis, and visible alterations in body image due to vascular access or complications [ 6 – 7 ]. This internalized and perceived stigma can precipitate a cascade of negative outcomes, including depression, social isolation, and diminished self-worth, which collectively erode psychological health and QoL [ 8 ]. Concurrently, suboptimal medication adherence persists as a major clinical challenge in MHD management. The complex regimen required to manage comorbidities—such as hyperphosphatemia, hypertension, and anemia—necessitates long-term use of multiple medications [ 9 ]. Poor adherence is a well-established independent risk factor for uncontrolled complications, increased hospitalization rates, higher mortality, and escalated healthcare costs [ 10 ]. Traditional research has predominantly investigated objective barriers to adherence, including polypharmacy, financial cost, and side effects [ 11 ]. Nevertheless, a critical gap remains in understanding the influence of intrinsic psychological factors, particularly stigma, on treatment behaviors. Grounded in Social Cognitive Theory and the Theory of Planned Behavior, stigma is posited to impair adherence through several pathways: by diminishing self-efficacy and treatment belief, reducing engagement with social support networks that facilitate adherence, and fostering a sense of hopelessness that leads to health negligence [ 12 ]. Despite its potential significance, the specific relationship between stigma and medication adherence in the MHD population has not been sufficiently elucidated. Therefore, this study aimed to address this knowledge gap by pursuing three specific objectives: (1) to assess the prevalence and level of stigma among patients undergoing MHD; (2) to examine the association between stigma and key sociodemographic and clinical characteristics; and (3) to investigate whether stigma is an independent predictor of medication adherence. By exploring this underexamined link, our findings seek to enrich the psychosocial understanding of MHD patients' health behaviors and provide a novel evidence base for developing targeted, multifaceted interventions to improve clinical outcomes. 2. Materials and methods 2.1 Study Design and Participants This was a single-center, cross-sectional study conducted between June 1 and December 2025. A convenience sample of patients was recruited from the Hemodialysis Center of Liwan Central Hospital, a tertiary hospital in Guangzhou, China. Inclusion criteria were: (1) age ≥ 20 years; (2) diagnosis of ESRD and receiving regular in-center hemodialysis for ≥ 3 months; (3) clear consciousness, intact cognitive function, and ability to communicate verbally. Exclusion criteria included: (1) comorbid active malignancy; (2) acute critical illness (e.g., acute infection, severe sequelae of cerebrovascular accident); (3) known history of psychiatric disorders; (4) major physical disability (e.g., amputation). A total of 136 eligible patients were invited, and 132 completed the survey, yielding a response rate of 97.1%. The sample size was deemed adequate for regression analysis based on the rule of thumb of a minimum of 10 participants per predictor variable [ 13 ], considering the planned number of independent variables. 2.2 Measures (1) General Information Questionnaire. A self-administered questionnaire was developed based on literature review to collect sociodemographic data (age, gender, education, employment, income, marital status) and clinical characteristics (dialysis vintage, mobility status, presence of dialysis-related chronic complications, primary medical payment method). Stigma Scale for Chronic Illness (SSCI). Stigma was assessed using the validated Chinese version of the SSCI [ 14 – 15 ]. This 24-item scale comprises two subscales: internalized stigma (13 items) and externalized stigma (11 items). Items are rated on a 5-point Likert scale from 1 (“never”) to 5 (“always”). The total score ranges from 24 to 120, with higher scores indicating greater perceived stigma. The Chinese version has demonstrated excellent reliability (Cronbach’s α = 0.951) and validity [ 15 – 16 ]. In the present study, Cronbach’s α for the total scale was 0.936. Medication Adherence. Adherence was measured using the Chinese version of the 8-item Morisky Medication Adherence Scale (MMAS-8) [ 17 ]. The use of the MMAS-8 was licensed from the copyright holder (Licence Number: 186101192026).The scale consists of 7 items with yes/no responses and one item on a 5-point Likert scale. The total score ranges from 0 to 8, where scores of < 6, 6 to < 8, and 8 indicate low, medium, and high adherence, respectively. The scale has shown good reliability and validity in Chinese patient populations (Cronbach’s α = 0.81) [ 18 ]. In this study, its Cronbach’s α was 0.79. 2.3 Data Collection Procedure Data collection was conducted by trained research assistants during patients’ routine dialysis sessions. The purpose of the study and confidentiality assurances were explained to each participant. Participants who provided written informed consent completed the questionnaires independently in a private area of the dialysis unit. For patients with visual impairment or fatigue, the research assistants read the items aloud and recorded their responses verbatim. All questionnaires were collected and checked for completeness on-site. 2.4 Ethical Considerations The study protocol was reviewed and approved by the Institutional Review Board (Ethics Committee) of Liwan Central Hospital, Guangzhou (Approval No: 2025017). The study was conducted in full accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all individual participants included in the study. 2.5 Statistical analysis Data were analyzed using IBM SPSS Statistics for Windows, Version 27.0 (Armonk, NY: IBM Corp). Descriptive statistics were presented as mean ± standard deviation (SD) for continuous variables and as frequency (percentage) for categorical variables. Group differences in total stigma scores across categorical variables were examined using independent samples t-tests (for two groups) or one-way analysis of variance (ANOVA) with Tukey’s post-hoc test (for more than two groups). The Pearson correlation coefficient was calculated to assess the bivariate relationship between stigma (total score) and MMAS-8 score. To identify independent factors associated with stigma, a multiple linear regression analysis was performed with the total SSCI score as the dependent variable. All variables showing a significant association with stigma in the univariate analyses ( P < 0.05) were entered as candidate independent variables. Categorical variables with more than two levels (e.g., marital status, education level) were dummy-coded before entry into the model. The final model was constructed using the enter method. The variance inflation factor (VIF) was examined to check for multicollinearity, with VIF < 5 considered acceptable. Model fit was assessed using the adjusted R². A two-tailed P -value < 0.05 was considered statistically significant for all tests. 3. Results 3.1 Current Status of Stigma A total of 132 patients undergoing maintenance hemodialysis (MHD) were included in this study. As shown in Table 1 , the overall stigma score among the participants was 65.39 ± 11.31 points. The scores for the internalized and externalized stigma subscales were 39.69 ± 8.46 and 25.70 ± 3.57 points, respectively. The average score per item was 2.71 ± 0.45, indicating a moderate level of overall stigma experience in this population. Table 1 Current Status of Stigma in MHD Patients (N = 132, points,, Mean ± SD) Item Total Score Mean Score per Item Internalized Stigma 40.13 ± 8.37 3.08 ± 0.65 Externalized Stigma 25.70 ± 3.57 2.33 ± 0.32 Total Stigma Score 65.82 ± 11.06 2.71 ± 0.45 3.2 Univariate Analysis of Stigma Across Different Characteristics The associations between stigma scores and various sociodemographic and clinical characteristics are detailed in Table 2 . Statistically significant differences in stigma levels ( P < 0.05) were observed across categories of age, education level, employment status, monthly income, marital status, mobility status, dialysis vintage, and the presence of dialysis-related chronic complications. Specifically, stigma scores tended to be higher among older patients, those with lower education or income, the unemployed or retired, widowed individuals, patients with limited mobility, those with longer dialysis duration, and those experiencing complications. No significant differences were found based on gender or medical payment method ( P > 0.05). Table 2 Comparison of Stigma Scores in MHD Patients with Different Characteristics [N = 132, points, Mean ± SD] Item Number of Cases (%) Score F / t P Gender 2.82 0.09 Male 79(59.8) 63.64 ± 11.52 Female 53(40.2) 69.07 ± 9.55 Age 15.47 < 0.001 ≥ 20 ≥ 20 7(5.3) 51.00 ± 12.58 20–39 40(30.3) 61.15 ± 12.03 40–59 37(28.0) 65.62 ± 8.63 ≥ 60 ≥ 60 48(36.4) 72.04 ± 7.28 Education Level 4.17 < 0.001 Primary School or Below 2(1.5) 75.0 ± 11.3 Junior High School 12(9.1) 73.00 ± 6.00 Senior High School or Technical Secondary School 75(56.8) 66.57 ± 11.45 Bachelor's Degree or Associate Degree 43(32.6) 62.09 ± 10.16 Medical Payment Method 1.21 0.334 Government-funded 21(15.9) 58.20 ± 15.46 Medical Insurance 111(84.1) 64.80 ± 11.84 Employment Status 33.96 < 0.001 Employed 54(40.0) 57.43 ± 10.65 Retired 66(50.0) 66.25 ± 11.36 Unemployed 12(9.1) 71.75 ± 7.03 Monthly Income (RMB) 18.40 < 0.001 < 2000 11(8.3) 65.90 ± 9.66 2000–2999 50(37.9) 72.14 ± 7.4 3000–3999 33(25.0) 66.18 ± 9.51 ≥ 4000 38(28.8) 57.18 ± 10.96 Marital Status 12.50 < 0.001 Unmarried 27(20.5) 56.03 ± 12.09 Married 98(74.2) 67.93 ± 9.03 Widowed 4(3.0) 79.75 ± 9.77 Divorced 3(2.3) 70.33 ± 3.21 Dialysis Vintage 9.83 < 0.001 < 2 years 40(30.3) 59.77 ± 9.83 2–5 years 56(42.4) 66.25 ± 11.69 6–10 years 23(17.4) 70.08 ± 6.51 10 years 13(9.8) 75.07 ± 8.28 Mobility Status 25.71 < 0.001 Normal walking 66(50.0) 60.18 ± 10.63 Walking with difficulty, requires support 32(24.2) 69.03 ± 8.64 Walking with great difficulty, requires wheelchair 34(25.8) 73.76 ± 7.38 Presence of Dialysis-Related Chronic Complications 13.23 < 0.001 Yes 117(88.6) 67.02 ± 10.60 No 15(11.4) 53.46 ± 10.39 3.3 Correlation Between Stigma and Medication Adherence The mean medication adherence score for the cohort was 3.67 ± 1.46. Pearson correlation analysis revealed a statistically significant negative correlation between the total stigma score and medication adherence (r = -0.464, P < 0.01), suggesting that higher levels of stigma are associated with poorer medication-taking behavior. 3.4 Multivariate Analysis of Factors Influencing Stigma A multiple linear regression analysis was conducted to identify independent factors associated with stigma. Variables demonstrating significant associations in the univariate analyses were entered as independent variables, with categorical variables dummy-coded as specified in Table 3 , and the total stigma score served as the dependent variable. The resulting model was statistically significant ( F = 6.983, P < 0.001) and explained 48.9% of the variance in stigma scores (Adjusted R² = 0.489). As detailed in Table 4 , the analysis identified five significant independent predictors. Being widowed ( b = 13.813, P < 0.01) and requiring wheelchair assistance due to walking difficulty ( b = 4.915, P < 0.01) were associated with substantially higher stigma levels. Furthermore, lower medication adherence was a significant independent predictor of greater stigma ( b = -1.813, P 10 years) ( b = 7.346, P < 0.05) and the presence of dialysis-related complications ( b = 5.091, P < 0.05) were also significantly associated with elevated stigma scores. Table 3 Assignment of Variables and Dummy Variable Settings Variable Name Assignment Method Age (years) ≥ 20 (Z1 = 0, Z2 = 0, Z3 = 0), 20–39 (Z1 = 1, Z2 = 0, Z3 = 0), 40–59 (Z1 = 0, Z2 = 1, Z3 = 0), ≥ 60 (Z1 = 0, Z2 = 0, Z3 = 1) Marital Status Unmarried (Z1 = 0, Z2 = 0, Z3 = 0), Married (Z1 = 1, Z2 = 0, Z3 = 0), Widowed (Z1 = 0, Z2 = 1, Z3 = 0), Divorced (Z1 = 0, Z2 = 0, Z3 = 1) Education Level Primary school or below (Z1 = 0, Z2 = 0, Z3 = 0), Junior high school (Z1 = 1, Z2 = 0, Z3 = 0), Senior high school or technical secondary school (Z1 = 0, Z2 = 1, Z3 = 0), Bachelor’s degree or associate degree (Z1 = 0, Z2 = 0, Z3 = 1) Employment Status Employed (Z1 = 0, Z2 = 0), Retired (Z1 = 1, Z2 = 0), Unemployed (Z1 = 0, Z2 = 1) Income Level < 2000 (Z1 = 0, Z2 = 0, Z3 = 0), 2000–2999 (Z1 = 1, Z2 = 0, Z3 = 0), 3000–3999 (Z1 = 0, Z2 = 1, Z3 = 0), ≥ 4000 (Z1 = 0, Z2 = 0, Z3 = 1) Mobility Status Normal walking (Z1 = 0, Z2 = 0), Walking with difficulty and requiring support (Z1 = 1, Z2 = 0), Walking with great difficulty and requiring wheelchair (Z1 = 0, Z2 = 1) Dialysis Vintage 10 years (Z1 = 0, Z2 = 0, Z3 = 1) Presence of Complications No = 0, Yes = 1 Medication Adherence Total score entered as numerical value Table 4 Results of Multiple Linear Regression Analysis of Influencing Factors Variable b SE β t P Constant 48.910 4.599 — 6.283 < 0.01 Widowed 13.813 5.201 0.215 2.656 < 0.01 Requires wheelchair due to walking difficulty 4.915 2.579 0.195 1.906 < 0.01 Medication adherence -1.813 0.510 -0.239 -3.555 10 years 7.346 3.259 0.141 2.535 < 0.05 Presence of complications 5.091 2.469 0.147 2.06 < 0.05 Note: b: unstandardized coefficient; SE: standard error; β: standardized coefficient; CI: confidence interval. Model: R 2 = 0.583, Adjusted R 2 = 0.489, F = 6.983, P < 0.001 4. Discussion This study investigated the status of stigma and its impact on medication adherence in patients undergoing MHD. The key findings indicate that MHD patients experience a moderate level of stigma, which is significantly influenced by sociodemographic and clinical factors, and importantly, serves as an independent negative predictor of medication adherence. These results underscore stigma as a critical psychosocial barrier in the management of chronic kidney disease. Our finding of a moderate overall stigma level (65.39 ± 11.31) aligns with previous research conducted in other chronic illness populations using the SSCI [ 14 , 16 ]. Notably, the score for internalized stigma was substantially higher than that for externalized stigma, suggesting that patients are more burdened by self-devaluation and shame than by perceived public discrimination. This aligns with Goffman’s theory that the internalization of negative societal labels profoundly damages self-identity [ 19 ]. For MHD patients, the constant reminder of dependency—on machines, healthcare systems, and often family members—likely fuels this internalized stigma, eroding self-efficacy and becoming a significant obstacle to positive health behaviors [ 20 , 21 ]. Marital status emerged as a significant psychosocial determinant. Widowed patients exhibited the highest stigma levels, whereas married patients reported relatively lower scores. This finding is consistent with literature emphasizing the protective role of spousal support in chronic disease adaptation [ 22 , 23 ]. A stable marital relationship typically provides emotional sustenance, practical assistance, and a buffer against social isolation, all of which may mitigate feelings of shame and difference. Conversely, the loss of a partner or the absence of such intimate support can exacerbate psychological vulnerability and stigma. Physical mobility impairment was another strong independent predictor of stigma. Patients requiring wheelchair assistance reported significantly higher stigma scores. Loss of mobility not only symbolizes a decline in physical autonomy but also directly restricts social participation and role fulfillment, reinforcing a patient’s identity around illness and dependency [ 24 , 25 ]. The visible need for assistive devices may further act as a public marker of disability, potentially attracting unwanted attention or discrimination, thus intensifying both external and internalized stigma. The core contribution of this study lies in establishing a significant negative correlation and identifying stigma as an independent predictor of poorer medication adherence. This relationship may be mediated through several pathways suggested by social cognitive models. High stigma can diminish self-worth and belief in a worthwhile future, reducing motivation for self-care [ 26 ]. It may also lead to social withdrawal, thereby limiting access to practical support or reminders for medication taking. Furthermore, the desire to avoid the additional “sick role” identity that medication rituals might reinforce could lead to intentional non-adherence [ 27 , 28 ]. This finding shifts the focus from purely practical barriers to adherence to include crucial psychosocial determinants. Contrary to the assumption that patients might adapt over time, our results indicated that longer dialysis vintage (> 10 years) was associated with higher stigma. This suggests that the cumulative burden of a life-sustaining yet intrusive treatment regimen may lead to chronic psychosocial distress rather than habituation [ 29 ]. The relentless cycle of treatment, coupled with progressive complications and social role attrition, can foster feelings of entrapment and hopelessness, potentially intensifying stigma over the long term [ 30 ]. The presence of dialysis-related complications was also independently associated with increased stigma. Complications such as severe pruritus, disfiguring calcifications, or debilitating bone pain serve as constant, tangible reminders of the disease, making it impossible for patients to mentally distance themselves from their illness [ 31 ]. These issues often increase care needs and financial strain, adding layers of burden that can fuel feelings of being a burden to others—a core component of internalized stigma [ 32 ]. These findings have direct implications for clinical practice. First, routine, systematic screening for stigma using validated tools like the SSCI should be integrated into the holistic assessment of MHD patients, particularly targeting high-risk groups (e.g., widowed, mobility-impaired, long-term patients). Second, interventions must move beyond general psychological support to address stigma specifically. This could include: (1) Establishing patient-led peer support groups to normalize experiences and reduce isolation; (2) Integrating cognitive-behavioral therapy techniques to challenge and reframe negative self-perceptions; (3) Providing family-centered education and counseling to enhance constructive support and communication; (4)Training dialysis staff to use stigma-sensitive communication and to foster an empowering treatment environment. This study has several limitations that must be considered when interpreting the results. First, its cross-sectional design precludes any causal inference regarding the relationship between stigma and medication adherence. Second, the use of a convenience sample from a single tertiary center limits the generalizability of the findings to the broader MHD population in other regions or healthcare settings. Third, reliance on self-reported measures for both stigma and adherence may introduce social desirability bias or common method variance. Finally, the sample size, while adequate for the primary analyses, may have limited the power to detect smaller effects among some subgroups. Future research should employ longitudinal or interventional designs across multiple centers to establish causality and test the efficacy of targeted stigma-reduction programs. 5. Conclusion In conclusion, this study reveals that stigma is a prevalent and multifaceted psychosocial burden among MHD patients, intricately linked to marital status, physical function, treatment duration, comorbidity burden, and critically, to poorer medication adherence. Addressing stigma requires a paradigm shift in MHD care, from a purely biomedical model to a biopsychosocial one. Proactive assessment and targeted, multidimensional interventions aimed at mitigating stigma are essential to improve not only psychological well-being but also key clinical outcomes such as treatment adherence in this vulnerable population. Declarations Author Contributions: Conceptualization, Guofeng Wu, methodology, Ben Tian, validation, Wenting Wu, formal analysis, Yanshan Huang and Cai Yitian, data curation, Shuying Yang and Biyi Wen, writing—original draft preparation, Shuying Yang, writing—review and editing, Guofeng Wu. All authors have read and agreed to the published version of the manuscript. Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of Guangzhou Liwan Central Hospital, the study has been granted the Ethical Approval Number: 2025017, and all participants provided written informed consent. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Consent for Publication: Not applicable Data Availability Statement: The raw data supporting the conclusions of this article will be made available by the authors on request. Acknowledgments: The use of the MMAS-8 was licensed from the copyright holder. Use of the MMAS is protected by US copyright laws. Permission for use is required. A license to use the Morisky scales can be obtained through MMAR, LLC, dba Adherence ( [email protected] ; www.moriskyscale.com). 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Biopsychosocial experiences and coping strategies of elderly ESRD patients: a qualitative study to inform the development of more holistic and person-centred health services in Singapore. BMC Public Health. 2019;19(1):1107. Published 2019 Aug 14. 10.1186/s12889-019-7433-6 Ye YY, Tao LF, Yang YL, Wang YW, Yang XM, Xu HH. Correlation between anxiety, depression, self-perceived burden, and psychological resilience in patients with chronic renal failure on maintenance hemodialysis. World J Psychiatry. 2025;15(7):103850. Published 2025 Jul 19. 10.5498/wjp.v15.i7.103850 Hagren B, Pettersen IM, Severinsson E, Lützén K, Clyne N. Maintenance haemodialysis: patients' experiences of their life situation. J Clin Nurs. 2005;14(3):294–300. 10.1111/j.1365-2702.2004.01036.x . Pretto CR, Rosa MBCD, Dezordi CM, Benetti SAW, Colet CF, Stumm EMF. Depression and chronic renal patients on hemodialysis: associated factors. Rev Bras Enferm. 2020;73(Suppl1):e20190167. 10.1590/0034-7167-2019-0167 . 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Guangzhou","correspondingAuthor":false,"prefix":"","firstName":"Yitian","middleName":"","lastName":"Cai","suffix":""},{"id":578344263,"identity":"72e90564-8235-4ab8-b674-97fd8cad8605","order_by":2,"name":"Biyi Wen","email":"","orcid":"","institution":"Liwan Central Hospital of Guangzhou","correspondingAuthor":false,"prefix":"","firstName":"Biyi","middleName":"","lastName":"Wen","suffix":""},{"id":578344270,"identity":"98df2d44-5789-4b57-ae75-506515a7c250","order_by":3,"name":"Yanshan Huang","email":"","orcid":"","institution":"Liwan Central Hospital of Guangzhou","correspondingAuthor":false,"prefix":"","firstName":"Yanshan","middleName":"","lastName":"Huang","suffix":""},{"id":578344272,"identity":"93899d35-5cfc-45f3-afc5-8df2d9ce3727","order_by":4,"name":"Wenting Wu","email":"","orcid":"","institution":"Liwan Central Hospital of Guangzhou","correspondingAuthor":false,"prefix":"","firstName":"Wenting","middleName":"","lastName":"Wu","suffix":""},{"id":578344281,"identity":"b1fbaf00-b94b-454c-9a9f-0d3a47a4eb26","order_by":5,"name":"Ben Tian","email":"","orcid":"","institution":"Liwan Central Hospital of Guangzhou","correspondingAuthor":false,"prefix":"","firstName":"Ben","middleName":"","lastName":"Tian","suffix":""},{"id":578344282,"identity":"60cdfae1-8fcb-42ef-a4fa-faf9057f65f4","order_by":6,"name":"Guofeng Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYBACPmYwdQDC+2BgY0dQCxtcCxsDA+OMgrRkwloYkLQw83w4xNhAUAs7j+Hngj935Mzlm49J2xgcYGZgP3x0A36H8RhLz2x7ZmzZxpYmnWNwh4+BJy3tBn4tvBukeRsOJ244xmMG1PKMmUGCx4yQls2/ef4crgdrsTA4zNhAhJZt0jxshxMMQFoYiNPC/82at+2w4YZjacmWPQZpyWyE/MLPfyz5NtBh8gaHDx+88eOPjR0/++FjeLVgsZc05aNgFIyCUTAKsAEA/d5CtpqC+tEAAAAASUVORK5CYII=","orcid":"","institution":"Liwan Central Hospital of 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14:12:51","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":100444,"visible":true,"origin":"","legend":"","description":"","filename":"b491cbdeadbb4ade99ef83c72be9d11c1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8530420/v1/324540857e5d849a91024705.xml"},{"id":100896002,"identity":"d01ca819-68c0-4d05-bfd9-a39c2b7e8a70","added_by":"auto","created_at":"2026-01-22 14:12:48","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":112056,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8530420/v1/95a00d160796e7e5888af93a.html"},{"id":104063913,"identity":"cf5f81aa-69df-476c-8d5d-87efbeca72e0","added_by":"auto","created_at":"2026-03-06 10:12:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":920799,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8530420/v1/04f1980a-a8da-4417-b43f-a8b0e3d83f28.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Analysis of Stigma Status and Its Impact on Medication Adherence in Patients Undergoing Maintenance Hemodialysis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eEnd-stage renal disease (ESRD) represents a formidable and escalating global public health burden, with its prevalence projected to rise steadily worldwide [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. In China, concurrent with an aging population and increasing rates of diabetes and hypertension, the incidence of ESRD has surged, imposing substantial demands on healthcare systems [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. For patients with ESRD, maintenance hemodialysis (MHD) serves as a cornerstone life-sustaining therapy, effectively prolonging survival [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the clinical paradigm is progressively shifting from a singular focus on mortality reduction towards a more holistic emphasis on improving patients' long-term quality of life (QoL) and psychosocial well-being [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003ePatients undergoing MHD constitute a distinct chronic illness population, frequently contending with a profound and detrimental psychosocial experience: stigma. Stigma arises from societal labeling, stereotyping, and discrimination associated with the illness and its demanding treatment regimen [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. For MHD patients, sources of stigma are multifactorial, encompassing misconceptions about kidney disease etiology, the intrusive and machine-dependent nature of dialysis, and visible alterations in body image due to vascular access or complications [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. This internalized and perceived stigma can precipitate a cascade of negative outcomes, including depression, social isolation, and diminished self-worth, which collectively erode psychological health and QoL [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eConcurrently, suboptimal medication adherence persists as a major clinical challenge in MHD management. The complex regimen required to manage comorbidities\u0026mdash;such as hyperphosphatemia, hypertension, and anemia\u0026mdash;necessitates long-term use of multiple medications [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. Poor adherence is a well-established independent risk factor for uncontrolled complications, increased hospitalization rates, higher mortality, and escalated healthcare costs [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. Traditional research has predominantly investigated objective barriers to adherence, including polypharmacy, financial cost, and side effects [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eNevertheless, a critical gap remains in understanding the influence of intrinsic psychological factors, particularly stigma, on treatment behaviors. Grounded in Social Cognitive Theory and the Theory of Planned Behavior, stigma is posited to impair adherence through several pathways: by diminishing self-efficacy and treatment belief, reducing engagement with social support networks that facilitate adherence, and fostering a sense of hopelessness that leads to health negligence [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite its potential significance, the specific relationship between stigma and medication adherence in the MHD population has not been sufficiently elucidated.\u003c/p\u003e\n\u003cp\u003eTherefore, this study aimed to address this knowledge gap by pursuing three specific objectives: (1) to assess the prevalence and level of stigma among patients undergoing MHD; (2) to examine the association between stigma and key sociodemographic and clinical characteristics; and (3) to investigate whether stigma is an independent predictor of medication adherence. By exploring this underexamined link, our findings seek to enrich the psychosocial understanding of MHD patients' health behaviors and provide a novel evidence base for developing targeted, multifaceted interventions to improve clinical outcomes.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design and Participants\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis was a single-center, cross-sectional study conducted between June 1 and December 2025. A convenience sample of patients was recruited from the Hemodialysis Center of Liwan Central Hospital, a tertiary hospital in Guangzhou, China.\u003c/p\u003e\u003cp\u003eInclusion criteria were: (1) age\u0026thinsp;\u0026ge;\u0026thinsp;20 years; (2) diagnosis of ESRD and receiving regular in-center hemodialysis for \u0026ge;\u0026thinsp;3 months; (3) clear consciousness, intact cognitive function, and ability to communicate verbally. Exclusion criteria included: (1) comorbid active malignancy; (2) acute critical illness (e.g., acute infection, severe sequelae of cerebrovascular accident); (3) known history of psychiatric disorders; (4) major physical disability (e.g., amputation).\u003c/p\u003e\u003cp\u003eA total of 136 eligible patients were invited, and 132 completed the survey, yielding a response rate of 97.1%. The sample size was deemed adequate for regression analysis based on the rule of thumb of a minimum of 10 participants per predictor variable [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], considering the planned number of independent variables.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Measures\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e(1) General Information Questionnaire. A self-administered questionnaire was developed based on literature review to collect sociodemographic data (age, gender, education, employment, income, marital status) and clinical characteristics (dialysis vintage, mobility status, presence of dialysis-related chronic complications, primary medical payment method).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStigma Scale for Chronic Illness (SSCI). Stigma was assessed using the validated Chinese version of the SSCI [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This 24-item scale comprises two subscales: internalized stigma (13 items) and externalized stigma (11 items). Items are rated on a 5-point Likert scale from 1 (\u0026ldquo;never\u0026rdquo;) to 5 (\u0026ldquo;always\u0026rdquo;). The total score ranges from 24 to 120, with higher scores indicating greater perceived stigma. The Chinese version has demonstrated excellent reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.951) and validity [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In the present study, Cronbach\u0026rsquo;s α for the total scale was 0.936.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMedication Adherence. Adherence was measured using the Chinese version of the 8-item Morisky Medication Adherence Scale (MMAS-8) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The use of the MMAS-8 was licensed from the copyright holder (Licence Number: 186101192026).The scale consists of 7 items with yes/no responses and one item on a 5-point Likert scale. The total score ranges from 0 to 8, where scores of \u0026lt;\u0026thinsp;6, 6 to \u0026lt;\u0026thinsp;8, and 8 indicate low, medium, and high adherence, respectively. The scale has shown good reliability and validity in Chinese patient populations (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.81) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In this study, its Cronbach\u0026rsquo;s α was 0.79.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Collection Procedure\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eData collection was conducted by trained research assistants during patients\u0026rsquo; routine dialysis sessions. The purpose of the study and confidentiality assurances were explained to each participant. Participants who provided written informed consent completed the questionnaires independently in a private area of the dialysis unit. For patients with visual impairment or fatigue, the research assistants read the items aloud and recorded their responses verbatim. All questionnaires were collected and checked for completeness on-site.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Ethical Considerations\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e The study protocol was reviewed and approved by the Institutional Review Board (Ethics Committee) of Liwan Central Hospital, Guangzhou (Approval No: 2025017). The study was conducted in full accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eData were analyzed using IBM SPSS Statistics for Windows, Version 27.0 (Armonk, NY: IBM Corp). Descriptive statistics were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) for continuous variables and as frequency (percentage) for categorical variables.\u003c/p\u003e \u003cp\u003eGroup differences in total stigma scores across categorical variables were examined using independent samples t-tests (for two groups) or one-way analysis of variance (ANOVA) with Tukey\u0026rsquo;s post-hoc test (for more than two groups). The Pearson correlation coefficient was calculated to assess the bivariate relationship between stigma (total score) and MMAS-8 score.\u003c/p\u003e \u003cp\u003eTo identify independent factors associated with stigma, a multiple linear regression analysis was performed with the total SSCI score as the dependent variable. All variables showing a significant association with stigma in the univariate analyses (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were entered as candidate independent variables. Categorical variables with more than two levels (e.g., marital status, education level) were dummy-coded before entry into the model. The final model was constructed using the enter method. The variance inflation factor (VIF) was examined to check for multicollinearity, with VIF\u0026thinsp;\u0026lt;\u0026thinsp;5 considered acceptable. Model fit was assessed using the adjusted R\u0026sup2;. A two-tailed \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for all tests.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Current Status of Stigma\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA total of 132 patients undergoing maintenance hemodialysis (MHD) were included in this study. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the overall stigma score among the participants was 65.39\u0026thinsp;\u0026plusmn;\u0026thinsp;11.31 points. The scores for the internalized and externalized stigma subscales were 39.69\u0026thinsp;\u0026plusmn;\u0026thinsp;8.46 and 25.70\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57 points, respectively. The average score per item was 2.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45, indicating a moderate level of overall stigma experience in this population.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCurrent Status of Stigma in MHD Patients (N\u0026thinsp;=\u0026thinsp;132, points,, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean Score per Item\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternalized Stigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.13\u0026thinsp;\u0026plusmn;\u0026thinsp;8.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternalized Stigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e25.70\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Stigma Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e65.82\u0026thinsp;\u0026plusmn;\u0026thinsp;11.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Univariate Analysis of Stigma Across Different Characteristics\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe associations between stigma scores and various sociodemographic and clinical characteristics are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Statistically significant differences in stigma levels (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were observed across categories of age, education level, employment status, monthly income, marital status, mobility status, dialysis vintage, and the presence of dialysis-related chronic complications. Specifically, stigma scores tended to be higher among older patients, those with lower education or income, the unemployed or retired, widowed individuals, patients with limited mobility, those with longer dialysis duration, and those experiencing complications. No significant differences were found based on gender or medical payment method (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Stigma Scores in MHD Patients with Different Characteristics [N\u0026thinsp;=\u0026thinsp;132, points, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Cases (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e/\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79(59.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e63.64\u0026thinsp;\u0026plusmn;\u0026thinsp;11.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53(40.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e69.07\u0026thinsp;\u0026plusmn;\u0026thinsp;9.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;20\u0026thinsp;\u0026ge;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e51.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40(30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e61.15\u0026thinsp;\u0026plusmn;\u0026thinsp;12.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37(28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e65.62\u0026thinsp;\u0026plusmn;\u0026thinsp;8.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;60\u0026thinsp;\u0026ge;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48(36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e72.04\u0026thinsp;\u0026plusmn;\u0026thinsp;7.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary School or Below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2(1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e75.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e73.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior High School or Technical Secondary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75(56.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e66.57\u0026thinsp;\u0026plusmn;\u0026thinsp;11.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor's Degree or Associate Degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43(32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e62.09\u0026thinsp;\u0026plusmn;\u0026thinsp;10.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedical Payment Method\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.334\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment-funded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21(15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e58.20\u0026thinsp;\u0026plusmn;\u0026thinsp;15.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical Insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e111(84.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e64.80\u0026thinsp;\u0026plusmn;\u0026thinsp;11.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54(40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e57.43\u0026thinsp;\u0026plusmn;\u0026thinsp;10.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66(50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e66.25\u0026thinsp;\u0026plusmn;\u0026thinsp;11.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e71.75\u0026thinsp;\u0026plusmn;\u0026thinsp;7.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly Income (RMB)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11(8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e65.90\u0026thinsp;\u0026plusmn;\u0026thinsp;9.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2000\u0026ndash;2999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50(37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e72.14\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3000\u0026ndash;3999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33(25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e66.18\u0026thinsp;\u0026plusmn;\u0026thinsp;9.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38(28.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e57.18\u0026thinsp;\u0026plusmn;\u0026thinsp;10.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27(20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e56.03\u0026thinsp;\u0026plusmn;\u0026thinsp;12.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98(74.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e67.93\u0026thinsp;\u0026plusmn;\u0026thinsp;9.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4(3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e79.75\u0026thinsp;\u0026plusmn;\u0026thinsp;9.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3(2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e70.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDialysis Vintage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40(30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e59.77\u0026thinsp;\u0026plusmn;\u0026thinsp;9.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56(42.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e66.25\u0026thinsp;\u0026plusmn;\u0026thinsp;11.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23(17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e70.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13(9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e75.07\u0026thinsp;\u0026plusmn;\u0026thinsp;8.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMobility Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal walking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66(50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e60.18\u0026thinsp;\u0026plusmn;\u0026thinsp;10.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWalking with difficulty, requires support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32(24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e69.03\u0026thinsp;\u0026plusmn;\u0026thinsp;8.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWalking with great difficulty, requires wheelchair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34(25.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e73.76\u0026thinsp;\u0026plusmn;\u0026thinsp;7.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresence of Dialysis-Related Chronic Complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e117(88.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e67.02\u0026thinsp;\u0026plusmn;\u0026thinsp;10.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15(11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e53.46\u0026thinsp;\u0026plusmn;\u0026thinsp;10.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Correlation Between Stigma and Medication Adherence\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe mean medication adherence score for the cohort was 3.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.46. Pearson correlation analysis revealed a statistically significant negative correlation between the total stigma score and medication adherence (r = -0.464, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), suggesting that higher levels of stigma are associated with poorer medication-taking behavior.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Multivariate Analysis of Factors Influencing Stigma\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA multiple linear regression analysis was conducted to identify independent factors associated with stigma. Variables demonstrating significant associations in the univariate analyses were entered as independent variables, with categorical variables dummy-coded as specified in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, and the total stigma score served as the dependent variable. The resulting model was statistically significant (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6.983, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and explained 48.9% of the variance in stigma scores (Adjusted R\u0026sup2; = 0.489). As detailed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the analysis identified five significant independent predictors. Being widowed (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13.813, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and requiring wheelchair assistance due to walking difficulty (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.915, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) were associated with substantially higher stigma levels. Furthermore, lower medication adherence was a significant independent predictor of greater stigma (\u003cem\u003eb\u003c/em\u003e = -1.813, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Additionally, longer dialysis vintage (\u0026gt;\u0026thinsp;10 years) (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.346, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and the presence of dialysis-related complications (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.091, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were also significantly associated with elevated stigma scores.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssignment of Variables and Dummy Variable Settings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable Name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssignment Method\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;20 (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;0), 20\u0026ndash;39 (Z1\u0026thinsp;=\u0026thinsp;1, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;0), 40\u0026ndash;59 (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;1, Z3\u0026thinsp;=\u0026thinsp;0), \u0026ge;\u0026thinsp;60 (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnmarried (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;0), Married (Z1\u0026thinsp;=\u0026thinsp;1, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;0), Widowed (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;1, Z3\u0026thinsp;=\u0026thinsp;0), Divorced (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school or below (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;0), Junior high school (Z1\u0026thinsp;=\u0026thinsp;1, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;0), Senior high school or technical secondary school (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;1, Z3\u0026thinsp;=\u0026thinsp;0), Bachelor\u0026rsquo;s degree or associate degree (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0), Retired (Z1\u0026thinsp;=\u0026thinsp;1, Z2\u0026thinsp;=\u0026thinsp;0), Unemployed (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncome Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2000 (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;0), 2000\u0026ndash;2999 (Z1\u0026thinsp;=\u0026thinsp;1, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;0), 3000\u0026ndash;3999 (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;1, Z3\u0026thinsp;=\u0026thinsp;0), \u0026ge;\u0026thinsp;4000 (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMobility Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal walking (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0), Walking with difficulty and requiring support (Z1\u0026thinsp;=\u0026thinsp;1, Z2\u0026thinsp;=\u0026thinsp;0), Walking with great difficulty and requiring wheelchair (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDialysis Vintage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 years (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;0), 2\u0026ndash;5 years (Z1\u0026thinsp;=\u0026thinsp;1, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;0), 6\u0026ndash;10 years (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;1, Z3\u0026thinsp;=\u0026thinsp;0), \u0026gt;\u0026thinsp;10 years (Z1\u0026thinsp;=\u0026thinsp;0, Z2\u0026thinsp;=\u0026thinsp;0, Z3\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of Complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u0026thinsp;=\u0026thinsp;0, Yes\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication Adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal score entered as numerical value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of Multiple Linear Regression Analysis of Influencing Factors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48.910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.599\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.656\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRequires wheelchair due to walking difficulty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.915\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.579\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.906\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-1.813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.510\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.555\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDialysis vintage\u0026thinsp;\u0026gt;\u0026thinsp;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: b: unstandardized coefficient; SE: standard error; β: standardized coefficient; CI: confidence interval. Model: R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.583, Adjusted R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.489, \u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6.983, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study investigated the status of stigma and its impact on medication adherence in patients undergoing MHD. The key findings indicate that MHD patients experience a moderate level of stigma, which is significantly influenced by sociodemographic and clinical factors, and importantly, serves as an independent negative predictor of medication adherence. These results underscore stigma as a critical psychosocial barrier in the management of chronic kidney disease.\u003c/p\u003e \u003cp\u003eOur finding of a moderate overall stigma level (65.39\u0026thinsp;\u0026plusmn;\u0026thinsp;11.31) aligns with previous research conducted in other chronic illness populations using the SSCI [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Notably, the score for internalized stigma was substantially higher than that for externalized stigma, suggesting that patients are more burdened by self-devaluation and shame than by perceived public discrimination. This aligns with Goffman\u0026rsquo;s theory that the internalization of negative societal labels profoundly damages self-identity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. For MHD patients, the constant reminder of dependency\u0026mdash;on machines, healthcare systems, and often family members\u0026mdash;likely fuels this internalized stigma, eroding self-efficacy and becoming a significant obstacle to positive health behaviors [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMarital status emerged as a significant psychosocial determinant. Widowed patients exhibited the highest stigma levels, whereas married patients reported relatively lower scores. This finding is consistent with literature emphasizing the protective role of spousal support in chronic disease adaptation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A stable marital relationship typically provides emotional sustenance, practical assistance, and a buffer against social isolation, all of which may mitigate feelings of shame and difference. Conversely, the loss of a partner or the absence of such intimate support can exacerbate psychological vulnerability and stigma.\u003c/p\u003e \u003cp\u003ePhysical mobility impairment was another strong independent predictor of stigma. Patients requiring wheelchair assistance reported significantly higher stigma scores. Loss of mobility not only symbolizes a decline in physical autonomy but also directly restricts social participation and role fulfillment, reinforcing a patient\u0026rsquo;s identity around illness and dependency [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The visible need for assistive devices may further act as a public marker of disability, potentially attracting unwanted attention or discrimination, thus intensifying both external and internalized stigma.\u003c/p\u003e \u003cp\u003eThe core contribution of this study lies in establishing a significant negative correlation and identifying stigma as an independent predictor of poorer medication adherence. This relationship may be mediated through several pathways suggested by social cognitive models. High stigma can diminish self-worth and belief in a worthwhile future, reducing motivation for self-care [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. It may also lead to social withdrawal, thereby limiting access to practical support or reminders for medication taking. Furthermore, the desire to avoid the additional \u0026ldquo;sick role\u0026rdquo; identity that medication rituals might reinforce could lead to intentional non-adherence [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This finding shifts the focus from purely practical barriers to adherence to include crucial psychosocial determinants.\u003c/p\u003e \u003cp\u003eContrary to the assumption that patients might adapt over time, our results indicated that longer dialysis vintage (\u0026gt;\u0026thinsp;10 years) was associated with higher stigma. This suggests that the cumulative burden of a life-sustaining yet intrusive treatment regimen may lead to chronic psychosocial distress rather than habituation [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The relentless cycle of treatment, coupled with progressive complications and social role attrition, can foster feelings of entrapment and hopelessness, potentially intensifying stigma over the long term [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe presence of dialysis-related complications was also independently associated with increased stigma. Complications such as severe pruritus, disfiguring calcifications, or debilitating bone pain serve as constant, tangible reminders of the disease, making it impossible for patients to mentally distance themselves from their illness [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. These issues often increase care needs and financial strain, adding layers of burden that can fuel feelings of being a burden to others\u0026mdash;a core component of internalized stigma [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese findings have direct implications for clinical practice. First, routine, systematic screening for stigma using validated tools like the SSCI should be integrated into the holistic assessment of MHD patients, particularly targeting high-risk groups (e.g., widowed, mobility-impaired, long-term patients). Second, interventions must move beyond general psychological support to address stigma specifically. This could include: (1) Establishing patient-led peer support groups to normalize experiences and reduce isolation; (2) Integrating cognitive-behavioral therapy techniques to challenge and reframe negative self-perceptions; (3) Providing family-centered education and counseling to enhance constructive support and communication; (4)Training dialysis staff to use stigma-sensitive communication and to foster an empowering treatment environment. This study has several limitations that must be considered when interpreting the results. First, its cross-sectional design precludes any causal inference regarding the relationship between stigma and medication adherence. Second, the use of a convenience sample from a single tertiary center limits the generalizability of the findings to the broader MHD population in other regions or healthcare settings. Third, reliance on self-reported measures for both stigma and adherence may introduce social desirability bias or common method variance. Finally, the sample size, while adequate for the primary analyses, may have limited the power to detect smaller effects among some subgroups. Future research should employ longitudinal or interventional designs across multiple centers to establish causality and test the efficacy of targeted stigma-reduction programs.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn conclusion, this study reveals that stigma is a prevalent and multifaceted psychosocial burden among MHD patients, intricately linked to marital status, physical function, treatment duration, comorbidity burden, and critically, to poorer medication adherence. Addressing stigma requires a paradigm shift in MHD care, from a purely biomedical model to a biopsychosocial one. Proactive assessment and targeted, multidimensional interventions aimed at mitigating stigma are essential to improve not only psychological well-being but also key clinical outcomes such as treatment adherence in this vulnerable population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003eConceptualization, Guofeng Wu, methodology, Ben Tian,\u0026nbsp;validation, Wenting Wu, formal analysis, Yanshan Huang and Cai Yitian, data curation, Shuying Yang and Biyi Wen, writing—original draft preparation, Shuying Yang, writing—review and editing,\u0026nbsp;Guofeng Wu. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u003c/strong\u003eThe study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of Guangzhou Liwan Central Hospital, the study has been granted the Ethical Approval Number: 2025017, and all participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u003c/strong\u003eInformed consent was obtained from all subjects involved in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The raw data supporting the conclusions of this article will be made available by the authors on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e The use of the MMAS-8 was licensed from the copyright holder. Use of the MMAS is protected by US copyright laws. Permission for use is required. A license to use the Morisky scales can be obtained through MMAR, LLC, dba Adherence ([email protected]; www.moriskyscale.com).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This work was supported by the Science and Technology Plan Project of Liwan District, Guangzhou [Grant Number 202004039].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLiyanage T, Ninomiya T, Jha V, et al. Worldwide access to treatment for end-stage kidney disease: a systematic review. 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Rev Bras Enferm. 2020;73(Suppl1):e20190167. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/0034-7167-2019-0167\u003c/span\u003e\u003cspan address=\"10.1590/0034-7167-2019-0167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Maintenance hemodialysis, Stigma, Medication adherence, Psychosocial factors, Quality of life","lastPublishedDoi":"10.21203/rs.3.rs-8530420/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8530420/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePatients undergoing maintenance hemodialysis (MHD) often experience stigma, which may adversely affect their health behaviors. This study aimed to investigate the status of stigma and its impact on medication adherence in this population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted using a convenience sample of 132 MHD patients from a tertiary hospital in Guangzhou, China. Participants completed the Chinese versions of the Stigma Scale for Chronic Illness (SSCI) and the Morisky Medication Adherence Scale (MMAS-8), along with a general information questionnaire. Descriptive statistics, t-tests, ANOVA, Pearson correlation, and multiple linear regression were used for data analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean total stigma score was 65.39\u0026thinsp;\u0026plusmn;\u0026thinsp;11.31, indicating a moderate level. Stigma scores significantly differed across age, education, employment, income, marital status, mobility, dialysis vintage, and presence of complications (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). A significant negative correlation was found between stigma and medication adherence (r = -0.464, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Multiple linear regression identified being widowed, requiring wheelchair assistance, longer dialysis vintage (\u0026gt;\u0026thinsp;10 years), presence of complications, and lower medication adherence as significant factors associated with higher stigma (Adjusted R\u0026sup2; = 0.489).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMHD patients experience considerable stigma, which is negatively associated with medication adherence. Healthcare providers should implement comprehensive assessments and targeted psychosocial interventions to mitigate stigma and improve treatment adherence in this vulnerable group.\u003c/p\u003e","manuscriptTitle":"The Analysis of Stigma Status and Its Impact on Medication Adherence in Patients Undergoing Maintenance Hemodialysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 14:10:54","doi":"10.21203/rs.3.rs-8530420/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"130d04ad-1673-41f5-bcd4-ea9256397e86","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-06T10:10:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 14:10:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8530420","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8530420","identity":"rs-8530420","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}