Associations of Helicobacter pylori infection with stigma and the mediating roles of anxiety and depression: a combination of cross-sectional and cohort study

Associations of Helicobacter pylori infection with stigma and the mediating roles of anxiety and depression: a combination of cross-sectional and cohort study | 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 Associations of Helicobacter pylori infection with stigma and the mediating roles of anxiety and depression: a combination of cross-sectional and cohort study Jumei Yin, Huan Zhang, Ju Zhang, Nuo Yao, Zheyi Han, Yongquan Shi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6139815/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 Stigma is common in certain infectious diseases and infection-related cancer. Helicobacter pylori (H. pylori) is infectious and related to gastric cancer. However, little is known about the relationship between H. pylori infection and stigma. Therefore, our study aims to investigate stigma and its influencing factors among patients with H. pylori infection. Materials and Methods 1144 participants were recruited from a tertiary hospital in northwest China from October 2023 to July 2024. The research instruments comprised Social Impact Scale, Gastrointestinal Systemic Response Score Scale, Hospital Anxiety and Depression Scale, Short Form Health Survey 12, General Self-efficacy Scale and Social Support Rating Scale. Multiple linear regression analysis was conducted to examine the relationship between H. pylori infection and stigma, as well as influencing factors of stigma in infected patients. Mediation models were used to evaluate whether anxiety and depression mediate the relationship between H. pylori infection and stigma. Results Compared to non-infected patients, those with H. pylori infection had higher total stigma scores (34 vs 27 points, P < 0.001) and a larger proportion of moderate-severe stigma (24.69% vs 9.81%, P < 0.001). H. pylori infection was positively correlated with stigma (β 5.38, 95%CI 3.83–6.94, p < 0.001), with anxiety symptom and depressive symptom mediating 13.37% and 9.90% of this correlation, respectively. In H. pylori-infection patients, age, seeking psychological help, receiving treatment and anxiety symptoms were positively correlated with stigma, while higher income, self-efficacy and quality of life were negatively correlated. Conclusion H. pylori-related stigma is common among infected patients. Therefore, routine stigma assessment, professional mental health support, counseling services, and public education are recommended to reduce stigma in this subpopulation. Stigma Helicobacter pylori Depression Anxiety Mediation models Figures Figure 1 Figure 2 Figure 3 Introduction Stigma is a multifaceted and hierarchical social process characterized by the attribution of labels, perpetuation of stereotypes, and implementation of segregation, resulting in the deprivation of status and discrimination, all within the framework of power dynamics 1 . It negatively impacts individuals' well-being, hinders the implementation of psychosocial interventions, and affects health and social care services 2 . Additionally, disease-related stigma can also intensify patients' concerns and negative emotions, reducing treatment adherence and recovery 3 . While most stigma research has concentrated on psychiatric disorders, infectious diseases and cancer 4 – 6 , the relationship between the common Helicobacter pylori (H. pylori) infection and stigma remains underexplored, compelling us to delve deeper into this area. H. pylori, a highly infectious pathogen, infects over half of the global population, with an approximate 40% infection rate in our country 7 . Identified as a class I carcinogen 8 , it is closely linked to gastric cancer development 9 . Given its contagious nature and association with cancer, H. pylori-infected patients may face stigma due to the public's fear and misunderstanding of cancer, leading to social exclusion or discrimination. Previous studies have found common psychiatric comorbidities like depression and anxiety in infected individuals 10 , yet few directly examine the relationship between H. pylori infection and stigma. Therefore, This study aims to explore the stigma status and influencing factors in patients with H. pylori infection, providing new insights for their comprehensive management. By identifying the specific manifestations and impacts of stigma, we hope to offer practical guidance for clinicians to better support these patients and inform public health strategies to mitigate the stigma associated with H. pylori infection. This research not only fills a critical research gap but also advances theoretical frameworks and guiding future in-depth studies. Materials and methods Study participants The single-center prospective study was conducted at a tertiary hospital in northwest China from October 2023 to July 2024. Using the Kendall sample size estimation method, with 60 observed variabkes, the planned sample size was 900 participants aged 18 to 60 who tested for H. pylori. Participants were excluded if they had cognitive impairment, epilepsy, psychiatric disorders, AIDS/HIV infection, leprosy, tuberculosis, physical disabilities, psoriasis or vitiligo skin conditions, inflammatory bowel disease, post-enterostomy complications, burns on exposed areas (face, neck, limbs), a history of substance abuse or addiction issues or were diagnosed with malignancy or severe organ dysfunction. The final sample size was 1144 participants (563 with H. pylori infection and 581 without), with the study protocol approved and written consent obtained from all participants. Data collection Measures Demographic and disease-related questionnaire The questionnaire encompassed the following domains: Demographics (gender, age, body mass index (BMI), education level, marital status, employment status, household income, self-assessed economic pressure, living status, smoking and drinking status ect), disease-related information (H. pylori infection status (No (never infected), Yes (previous or current infection)), disease course, H. pylori eradication treatment, co-morbidities, gastric mucosal lesions, knowledge and acceptance of H. pylori among self, family members, friends, and colleagues, support from healthcare workers, perceived health status, etc). Social Impact Scale (SIS) The SIS is a widely utilized generic stigma scale for assessing stigma in patients with infectious diseases and cancer 11 . It includes 24 items across four dimensions: social rejection, financial insecurity, internalized shame and social isolation. The SIS items are rated on a scale from "1" (strongly disagree) to "4" (strongly agree), with total score ranging from 24 to 96. Higher score indicates more sever stigma. Based on the average score of each project, they are categorized three levels: low (1.00-1.99), moderate (2.00-2.99), and high (3.00–4.00). The Chinese version of the SIS has demonstrated good psychometric properties, with a Cronbach's α 0.940. Hospital Anxiety and Depression Scale (HADS) The HADS consists of two subscales: the HADS-Anxiety Scale (HADS-A) and the HADS-Depression Scale (HADS-D) 12 . Each subscales contains seven items, rated on a scale from 0 to 3. The total score for each subscale ranges from 0 to 21, with higher scores indicating more severe anxiety or depressive symptoms. The Gastrointestinal Symptom Rating Scale (GSRS) The GSRS, authorized by its original author Svedlund, was used in this study to evaluated gastrointestinal symptoms 13 . It includes 15 items categorized into 5 distinct symptom clusters: abdominal pain, reflux, diarrhea, dyspepsia, and constipation. Items are rated on a Likert-4 scale (0–3), with a total score of 45 points. Higher scores indicate more severe symptoms. The generic 12-item Short Form Health Survey (SF-12) The SF-12 is a self-administered questionnaire designed to assess an individual's health status across eight dimensions: general health, physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health 14 . These dimensions are summarized into two subscales: Physical Component Summary (PCS) and Mental Component Summary (MCS). Each question offers two to five answer options, and a scoring algorithm is used to assess health status, with higher scores indicating better health. The General Self-Efficacy Scale(GSES) and Social Support Rating Scale (SSRS) GSES 15 and SSRS 16 seach consist of 10 items, rated on a 4-point Likert scale ranging from 1 to 4. Higher scores on these scales indicate higher levels of self-efficacy and social support, respectively. Statistics Socio-demographic and clinical characteristics were described based on the H. pylori infection status at baseline. Continuous variables were presented as mean ± standard deviation or median ± interquartile range, and compared using independent two-sample t-tests or rank-sum tests. Categorical variables were assessed using the χ2 test and reported as percentages. Multiple linear regression analysis was used to investigate the relationship between H. pylori infection and stigma, and to identify the main factors affecting stigma in infected patients, based on significant intergroup differences found in univariate analysis and common demographic characteristics. Mediation analysis was conducted to explore the mediation effects of anxiety and depressive symptom on the relationship between H. pylori infection and stigma. Paired t-tests or paired rank sum tests were used to compare changes in SIS and SF-12 scores before and after treatment. Statistical analyses were proformed using SPSS 25.0 and R 4.2.2 software, with a significance level was set at 0.05 (two-tailed test). Results Baseline characteristics of study participants A total of 1144 participants, comprising 563 with H. pylori infection and 581 without, were recruited. The baseline characteristics by infection status are detailed in supplementary file table S1 . Patients with infection exhibited higher rates of disease duration exceeding one year, family infected, ulceration, gastric intestinal metaplasia, and intraepithelial neoplasia. They also showed greater awareness and acceptance of H. pylori infection among themselves as well as their social circles. Notably, the inflection group has significantly higher anxiety and depression scores, as well as higher SIS and subscale scores, while the incidence of functional gastrointestinal disorders and gastroesophageal reflux were lower compared to the control group (all P < 0.05). Figure 1 A revealed that patients with H. pylori infection had a higher rate of moderate-to-severe stigma at 24.69% compared to 9.81% for without infection. Following propensity score matching (PSM) (1:1) to balance the statistically different demographic and disease characteristics between the two groups, a cohort of 504 participants was selected, evenly split between infected and non-infected individuals (252 each). Post-matching, no differences in demographic and disease characteristics were observed between the groups, as detailed in supplementary file table S2. Despite this, patients with H. pylori infection continued to show a higher rate of moderate-to-severe stigma at 20.24% versus 7.94% for the non-infected group, as illustrated in Fig. 1 B. The relationship between Helicobacter pylori infection and stigma The relationship between H. pylori infection and stigma is shown in Fig. 2 . The multivariate linear regression analysis indicated that H. pylori infection is an independent predicted of stigma levels (β 5.38, 95%CI 3.83–6.94, p < 0.001) and is also positively associated with SIS subscale scores, as shown in supplementary file table S3. In subgroup analyses, we assessed the correlation between H. pylori infection and stigma across various demographic and clinical factor, including age (< 45 and 45–60), gender (male and female), BMI ( high scholl), marital status (other and married), employment status (unemployed and employed), perceived economic stress (low, middle, and high), disease duration (≤ 1 and > 1), and perceived health status (bad, general, and good). H. pylori infection was closely link to stigma in these subgroups, with a significant interaction only in the perceived economic pressure subgroup (P-interaction = 0.025). No significant interactions were found in the other subgroups (P-interaction > 0.05), as illustrated in Fig. 2 . Factors associated with stigma among patients with Helicobacter pylori infection Univariate analysis identified several facters significantly associated with stigma amomg patients with H. pylori infection, including family income, perceived economic stress, drinking status, living status, number of treatments received, acceptance from family, friends and colleagues regarding H. pylori infection, seeking psychological help, perceived health status, gastrointestinal symptoms, degree of anxiety and depression, self-efficacy, and physical and mental health (all p values < 0.05). Multivariate linear regression analysis further revealed that age, seeking psychological help, receiving treatment for H. pylori infection and anxiety were positively associated with stigma. In constrast, higher income level, greater self-efficacy, physical health and mental health were negatively associated with stigma (Table 1 ). Additionally, 258 patients who underwent eradication therapy were followed up, with 186 patients completing a follow-up questionnaire again. Paired rank sum test indicated that post-treatment, SIS score and subscale scores, as well as anxiety and depression scores, and gastrointestinal symptoms scores decreased, while quality of life subscale scores increased (Table 2 ). Table 1 Factors influencing stigma among patients with H. pylori infection Variables Unadjusted model Adjusted model b S.E t P β (95%CI) b S.E t P β (95%CI) Age 0.01 0.05 0.29 0.770 0.01 (-0.08 ~ 0.11) 0.12 0.05 2.19 0.029 0.12 (0.01 ~ 0.22) GSRS 0.57 0.13 4.37 < 0.001 0.57 (0.32 ~ 0.83) -0.05 0.12 -0.39 0.699 -0.05 (-0.28 ~ 0.19) GSES -0.81 0.09 -9.10 < 0.001 -0.81 (-0.98 ~ -0.63) -0.27 0.09 -3.00 0.003 -0.27 (-0.45 ~ -0.09) PCS -0.50 0.08 -6.18 < 0.001 -0.50 (-0.66 ~ -0.34) -0.23 0.09 -2.63 0.009 -0.23 (-0.40 ~ -0.06) MCS -0.57 0.05 -12.67 < 0.001 -0.57 (-0.66 ~ -0.49) -0.25 0.06 -4.28 < 0.001 -0.25 (-0.36 ~ -0.13) HADS A 1.89 0.14 13.47 < 0.001 1.89 (1.62 ~ 2.17) 1.02 0.20 5.11 < 0.001 1.02 (0.63 ~ 1.41) HADS D 1.74 0.17 10.48 < 0.001 1.74 (1.42 ~ 2.07) 0.08 0.21 0.37 0.715 0.08 (-0.33 ~ 0.48) Family income, n(%) < 2000 0.00 (Reference) 0.00 (Reference) 2000–7999 -7.51 3.12 -2.41 0.016 -7.51 (-13.63 ~ -1.39) -6.46 2.67 -2.42 0.016 -6.46 (-11.69 ~ -1.24) ≥ 8000 -9.49 3.03 -3.14 0.002 -9.49 (-15.42 ~ -3.56) -7.80 2.72 -2.86 0.004 -7.80 (-13.13 ~ -2.46) Perceived economic pressures, n(%) Low 0.00 (Reference) 0.00 (Reference) Middle 4.59 1.24 3.69 < 0.001 4.59 (2.15 ~ 7.03) 1.38 1.11 1.24 0.214 1.38 (-0.79 ~ 3.55) High 5.22 1.59 3.29 0.001 5.22 (2.11 ~ 8.33) 2.24 1.42 1.58 0.114 2.24 (-0.54 ~ 5.02) Drinker, n(%) Drinker 0.00 (Reference) 0.00 (Reference) Non-drinker 2.58 1.48 1.74 0.083 2.58 (-0.33 ~ 5.49) 0.48 1.45 0.33 0.739 0.48 (-2.36 ~ 3.33) Ex-drinker 6.61 2.71 2.44 0.015 6.61 (1.30 ~ 11.92) 4.45 2.64 1.68 0.093 4.45 (-0.73 ~ 9.63) Cure No 0.00 (Reference) 0.00 (Reference) Yes 4.28 2.49 1.72 0.086 4.28 (-0.60 ~ 9.16) 4.25 2.11 2.02 0.044 4.25 (0.12 ~ 8.38) Number of treatments, n(%) 0 0.00 (Reference) 0.00 (Reference) 1 1.98 1.19 1.67 0.096 1.98 (-0.35 ~ 4.31) -0.21 1.09 -0.19 0.846 -0.21 (-2.35 ~ 1.92) 2 4.22 1.78 2.38 0.018 4.22 (0.74 ~ 7.70) 0.85 1.62 0.52 0.602 0.85 (-2.33 ~ 4.03) ≥ 3 2.80 2.01 1.39 0.165 2.80 (-1.15 ~ 6.74) -1.28 1.90 -0.68 0.500 -1.28 (-5.01 ~ 2.44) Acceptance level Family, n(%) Low 0.00 (Reference) 0.00 (Reference) Middle -1.99 1.68 -1.18 0.237 -1.99 (-5.27 ~ 1.30) 1.77 4.67 0.38 0.704 1.77 (-7.38 ~ 10.93) High -3.41 1.46 -2.34 0.020 -3.41 (-6.26 ~ -0.55) -0.59 3.66 -0.16 0.871 -0.59 (-7.77 ~ 6.58) Friends and colleagues, n(%) Low Middle -2.22 1.68 -1.32 0.186 -2.22 (-5.52 ~ 1.07) -5.55 4.72 -1.18 0.240 -5.55 (-14.80 ~ 3.70) High -3.74 1.45 -2.58 0.010 -3.74 (-6.58 ~ -0.90) -2.79 3.62 -0.77 0.441 -2.79 (-9.88 ~ 4.30) Feel mental services helpful Low 0.00 (Reference) 0.00 (Reference) High 13.73 3.26 4.21 < 0.001 13.73 (7.33 ~ 20.13) 7.71 2.80 2.75 0.006 7.71 (2.22 ~ 13.21) Perceived health status, n(%) Bad 0.00 (Reference) 0.00 (Reference) General -9.34 1.71 -5.46 < 0.001 -9.34 (-12.69 ~ -5.98) -1.77 1.67 -1.06 0.290 -1.77 (-5.05 ~ 1.51) Good -14.39 1.80 -7.98 < 0.001 -14.39 (-17.92 ~ -10.85) -2.49 1.96 -1.27 0.206 -2.49 (-6.33 ~ 1.36) Dwelling status, n(%) Live alone 0.00 (Reference) 0.00 (Reference) Live with spouse -6.13 2.34 -2.62 0.009 -6.13 (-10.71 ~ -1.55) -3.54 2.12 -1.67 0.096 -3.54 (-7.70 ~ 0.62) Others -4.18 1.99 -2.10 0.036 -4.18 (-8.09 ~ -0.28) -2.91 1.81 -1.61 0.108 -2.91 (-6.46 ~ 0.63) Gastric disease, n(%) Chronic non-atrophic gastritis 0.00 (Reference) 0.00 (Reference) Chronic atrophic gastritis 1.88 1.41 1.33 0.183 1.88 (-0.88 ~ 4.64) 1.74 1.21 1.44 0.151 1.74 (-0.63 ~ 4.12) Intestinal metaplasia and dysplasia 3.12 2.39 1.31 0.192 3.12 (-1.56 ~ 7.80) 0.27 2.11 0.13 0.900 0.27 (-3.87 ~ 4.40) Ulceration -2.04 2.62 -0.78 0.435 -2.04 (-7.17 ~ 3.08) 0.25 2.20 0.11 0.910 0.25 (-4.07 ~ 4.57) Others 0.49 1.43 0.34 0.734 0.49 (-2.32 ~ 3.30) 3.17 1.28 2.47 0.014 3.17 (0.66 ~ 5.68) CI: Confidence Interval Table 2 Paired rank sum compared the total stigma score and its subscale scores, anxiety and depression scores, and gastrointestinal symptoms scores and the quality of life subscale scores before and after treatment. Variables Before After Z P SIS 34.00 (26.00, 48.00) 24.00 (24.00, 27.00) -9.39 < 0.001 Social rejection 12.00 (9.00, 17.00) 9.00 (9.00, 9.00) -9.16 < 0.001 Financial insecurity 4.00 (3.00, 6.00) 3.00(3.00,4.00) -6.25 < 0.001 Internalized shame 9.00 (5.00, 13.00) 5.00 (5.00, 5.00) -8.3 < 0.001 Social isolation 10.00 (7.00, 14.00) 7.00 (7.00, 8.00) -8.68 < 0.001 HADS A 3.00 (1.00, 6.00) 0.00 (0.00, 1.25) -8.85 < 0.001 HADS D 5.00 (3.00, 7.00) 1.00 (1.00, 3.00) -9.27 < 0.001 SF12 PCS 45.29 (42.60, 48.00) 47.98 (44.98, 48.27) -2.63 < 0.001 MCS 52.67 (45.28, 57.21) 57.17 (51.40, 62.41) -4.4 < 0.001 GSRS 5.00 (3.00, 8.00) 0.00 (0.00, 1.00) -10.4 < 0.001 Mediation of the association between Helicobacter pylori infection and stigma through anxiety and depressive symptom Supplementary file table S4 indicated that, after adjusting for all confounding factors, H. pylori infection was positively correlated with anxiety symptom (β ± SE = 0.62 ± 0.21, p = 0.003) and depressive symptom (β ± SE = 0.73 ± 0.21, p < 0.001). Furthermore, both anxiety and depressive symptom were significantly associated with stigma (β ± SE = 1.22 ± 0.11, p < 0.001; β ± SE = 0.81 ± 0.12, p < 0.001) (Supplementary file table S5). Figure 3 illustrated that anxiety and depressive symptom mediated the relationship between H. pylori infection and stigma. Specifically, for H. pylori infection, anxiety symptom and depressive symptom mediated 13.37% and 9.90% of the indirect effects on stigma, respectively. Discussion In our study, individuals with H. pylori-infected exhibited higher stigma compared to those without infection. Additionally, we also found an independent association between H. pylori infection and stigma, with anxiety and depressive symptom partially mediating this association. Further analysis in patients with H. pylori infection revealed that age, seeking psychological help, receiving treatment for H. pylori infection, as well as anxiety symptom were positively associated with stigma. Conversely, higher income level, greater self-efficacy, and better physical and mental health were negative association with stigma. Additionlly, eradication therapy reduced the stigma experienced by infected patients. H. pylori gastritis has been officially recognized as an infectious disease in the 2015 Kyoto Global Consensus Report on Helicobacter pylori 17 . Numerous studies have consistently shown the stigma is prevalent among patients with various infectious diseases. Indeed, a meta-analysis involving 92,722 participants showed that approximately 38% of patients with infectious diseases such as atypical pneumonia, influenza A (H1N1), Middle East respiratory syndrome, Zika virus disease, Ebola virus disease, and COVID-19 experienced stigma 18 . Similarly, among sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), genital herpes, syphilis, viral hepatitis, gonorrhoea, vaginal trichomoniasis, and pubic pediculosis, some people are reluctant to disclose disclose their STIs, Even when notified of a positive test result, they may delay testing, refuse to seek treatment, and fail to inform their partners 19 . Furthermore, stigma is also common among patients with leprosy and tuberculosis 20 . However, there is a lack of epidemiological surveys describing the incidence of stigma in patients with H. pylori infection. In this study, among 1144 patients, the median total stigma score was 30, and 17.13% of the participants experienced moderate-high levels of stigma. The H. pylori infection group had a higher total stigma score compared to the control group. Similarly, previous studies have reported stigma in patients with certain malignant tumors, such as lung cancer 21 , breast cancer 22 and head and neck neoplasms 23 . Likewise, stigma is also prevalent in infection-related malignancies including cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers caused by human papillomavirus 19 , Leukemia and lymphoma due to HTLV 24 , and HIV -related malignancies like Kaposi's sarcoma 25 . Furtherore, H. pylori is recognized as a class I carcinogenic factor for gastric cancer by the International Agency for Research on Cancer and is closely link to gastric adenocarcinoma development 8 . Thus, consistent with these findings, our study showed that a greater proportion of patients with H. pylori infection experienced moderate-to-high levels of stigma compared with the control group. This suggest that while stigma levels in patients with H. pylori infection are generally lower than in those with malignant tumors, a significant number still face moderate-high stigma. Many demographic, disease-related, and psychosocial factors are associated with stigma in patients with infectious diseases or cancer 26 , 27 . Similarly, consistent with findings that higher income is associated with lower stigma in cancer patients 28 , our study found that higher incom is associated with lower stigma in patients with H. pylori infection. This may be because higher income can significantly reduce the psychological and financial stress caused by disease diagnosis and treatment. Conversely, while previous studies have shown that higher education levels reduces stigma in cancer and infectious diseases 29 , 30 , we did not find a significant association between education level and stigma in H. pylori infection, similar to findings by James et al 31 . Moreover, the relationship between age and stigma is inconsistent across studies. Some show a negatively associated in lung cancer 21 and breast cancer 32 , while age is a risk factor for stigma in Crohn's disease 33 , mirroring our results. This may be due to decreased work ability and income with age, increasing the financial and care burden on families. Additionally, we found that anxiety symptoms were independently associated with stigma in patients with H. pylori infection, consistent with evidence in tuberculosis and HIV-Positive patients 34 . Previous studies have demonstrated a positive association between H. pylori infection and anxiety and the development of depression across various populations 35 . Moreover, H. pylori infection has been shown to increased anxiety and depressive behaviors in mouse models 36 . Notably, in our mediation analysis, anxiety and depressive symptom were found to partially mediate the relationship between H. pylori infection and stigma. These findings suggest that H. pylori infection may promote the onset of anxiety symptom and depressive symptom, thereby increasing the stigma experienced by patients with H. pylori infection, thus revealing potential mechanisms. Prior research has implicated the microbiota-gut-brain axis in the pathogenesis of various diseases 37 , including disorders of the gastrointestinal system 38 and psychiatric conditions 39 . The gastrointestinal (GI) tract is considered a sensory organ that transmits information to the brain, playing a crucial role in detecting, transmitting, integrating, and responding to signals from both internal and external environments, thereby influencing behavior and emotions 40 . The gut microbiota is essential for facilitating bidirectional communication between the gastrointestinal tract and the central nervous system. H. pylori infection can modulate the composition of gut microbiota and impact the physiological state of the gut-brain axis (GBA) 41 . Furthermore, the presence of H. pylori can modulate the level of inflammation in the body 42 . In the cellular experiment, H. pylori strains co-cultured with neurons and neuron-astrocytes have been shown to increase reactive oxygen species (ROS) production and inflammatory response within these cells 43 . Additionally, some studies have found that H. pylori can induce the release of pro-inflammatory cytokines, such as interleukin (IL) -8, from gastric epithelial cells 44 . These inflammatory cytokines can have a significant effect on GBA activity 45 . The strength of this study lies in the use of 13/14C-UBT and gastric mucosal biopsy as diagnostic markers for H. pylori infection, which offer near 100% specificity and sensitivity. However, our study has limitations. Firstly, being a cross-sectional study, it cannot establish causal relationships. Secondly, although we adjusted for may potential confounders, some relevant factors may remain unaccounted for. third, The study's results may be influenced by traditional Chinese culture; so caution is needed when applying these findings to other populations. This study is an initial exploreation of the stigma experienced by patient with H. pylori infection, highlighting the need for future studies with larger sample sizes and longitudinal designs to further investigate this phenomenon. Conclusion This study shown that H. pylori infection is an independent risk factor for stigma, with 24.69% of patients with H. pylori infected experiencing moderate-high levels of stigma. Facters influencing stigma in these patients included age, income, receiving treatment, seeking psychological help, anxiety symptom, self-efficacy, and physical and mental health. Therefore, medical professionals should closely monitor the stigma levels in patients with H. pylori infection who are older, have lower family income and self-efficacy, and present with anxiety. Abbreviations H. pylori Helicobacter pylori SIS Social Impact Scale GSRS Gastrointestinal Systemic Response Score Scale HADS Hospital Anxiety and Depression Scale HADS-A HADS-Anxiety Scale HADS-D HADS-Depression Scale SF-12 Short Form Health Survey 12 PCS Physical Component Summary MCS Mental Component Summary GSES General Self-efficacy Scale SSRS Social Support Rating Scale Declarations Ethics approval: in accordance with the Declaration of Helsinki, the study was approved by the Ethics Committee of Xijing Hospital (KY20242348). All participants provided informed written consent at enrollment. Clinical trial number: not applicable Consent for publication: Written informed consent was obtained from the patient for publication. Data availability statement: All data of the study are presented in the text or supplementary materials. Conflict of interest: The authors declare that they have no competing interests. Funding statement: This work was supported by grants from Shaanxi Key Research Innovation & Development Project (No. 2023-ZDLSF-35). Author Contributions: Conceptualization and design, Z.H., Y.S.; methodology, J.Y., software, J.Z.; formal analysis, J.Y., H.Z., and N.Y.; data curation, J.Y.; draft, J.Y.; review and editing, J.Y.; supervision, Y.S., and Z.H. All authors have read and agreed to the published version of the manuscript. Acknowledgments: We sincerely appreciate the staff and participants for making invaluable efforts and contributions. References Nyblade L, Stockton MA, Giger K, et al. Stigma in health facilities: why it matters and how we can change it. BMC Med. 2019;17(1):25. 10.1186/s12916-019-1256-2 . Thornicroft G. 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Support Care Cancer. 2023;31(1):55. 10.1007/s00520-022-07506-4 . Heirman AN, Arends CR, De Jel DVC, et al. Decisional Conflict and Decision Regret in Head and Neck Oncology: A Systematic Review and Meta-Analysis. JAMA Otolaryngol Head Neck Surg. 2024;150(5):393. 10.1001/jamaoto.2024.0214 . Garcia IFDS, Hennington ÉA. HTLV: uma infecção estigmatizante? Cad Saúde Pública. 2019;35(11):e00005419. 10.1590/0102-311x00005419 . Potthoff A, Brockmeyer NH, HIV-assoziierte Tumore. Hautarzt. 2006;57(11):988–93. 10.1007/s00105-006-1223-7 . Huang Z. Correlates of stigma for patients with cancer: a systematic review and meta-analysis. Support Care Cancer. 2022;31(1):55. 10.1007/s00520-022-07506-4 . Logie C, Gadalla TM. Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care. 2009;21(6):742–53. 10.1080/09540120802511877 . Weiss J, Stephenson BJK, Edwards L, Rigney M, Copeland A. Public attitudes about lung cancer: stigma, support, and predictors of support. JMDH. 2014;293. 10.2147/JMDH.S65153 . Zhang TM, Fang Q, Yao H, Ran MS. Public Stigma of COVID-19 and Its Correlates in the General Population of China. Int J Environ Res Public Health. 2021;18(21):11718. 10.3390/ijerph182111718 . Thuné-Boyle ICV, Stygall J, Keshtgar MRS, Davidson TI, Newman SP. Religious/spiritual coping resources and their relationship with adjustment in patients newly diagnosed with breast cancer in the UK. Psychooncology. 2013;22(3):646–58. 10.1002/pon.3048 . James PB. An assessment of Ebola-related stigma and its association with informal healthcare utilisation among Ebola survivors in Sierra Leone: a cross-sectional study. BMC Public Health. 2020;20(1):182. 10.1186/s12889-020-8279-7 . Tang Wzhen. Correlates of stigma for patients with breast cancer: a systematic review and meta-analysis. Support Care Cancer. 2022;31(1):55. 10.1007/s00520-022-07506-4 . He D, He L, Yuan Y, et al. Stigma and its correlates among patients with Crohn’s disease: A cross-sectional study in China. Int J Nurs Sci. 2023;10(3):318–24. 10.1016/j.ijnss.2023.06.012 . Durteste M, Kyselyova G, Volokha A et al. Anxiety symptoms and felt stigma among young people living with perinatally or behaviourally-acquired HIV in Ukraine: A cross-sectional survey. Muñoz-Moreno JA, ed. PLoS ONE . 2019;14(1):e0210412. 10.1371/journal.pone.0210412 Simanek AM, Parry A, Dowd JB. Differences in the association between persistent pathogens and mood disorders among young- to middle-aged women and men in the U.S. Brain, Behavior, and Immunity . 2018;68:56–65. 10.1016/j.bbi.2017.09.017 Tian J, Wang Z, Ren Y et al. Rapamycin Attenuates Anxiety and Depressive Behavior Induced by Helicobacter pylori in Association with Reduced Circulating Levels of Ghrelin. Wyss JM, ed. Neural Plasticity . 2022;2022:1–8. 10.1155/2022/2847672 Aburto MR, Cryan JF. Gastrointestinal and brain barriers: unlocking gates of communication across the microbiota–gut–brain axis. Nat Rev Gastroenterol Hepatol. 2024;21(4):222–47. 10.1038/s41575-023-00890-0 . Fairbrass KM, Lovatt J, Barberio B, Yuan Y, Gracie DJ, Ford AC. Bidirectional brain–gut axis effects influence mood and prognosis in IBD: a systematic review and meta-analysis. Gut. 2022;71(9):1773–80. 10.1136/gutjnl-2021-325985 . Góralczyk-Bińkowska A, Szmajda-Krygier D, Kozłowska E. The Microbiota–Gut–Brain Axis in Psychiatric Disorders. IJMS. 2022;23(19):11245. 10.3390/ijms231911245 . Agirman G, Yu KB, Hsiao EY. Signaling inflammation across the gut-brain axis. Science. 2021;374(6571):1087–92. 10.1126/science.abi6087 . Baj J, Forma A, Flieger W, et al. Helicobacter pylori Infection and Extragastric Diseases—A Focus on the Central Nervous System. Cells. 2021;10(9):2191. 10.3390/cells10092191 . Carlessi AS, Borba LA, Zugno AI, Quevedo J, Réus GZ. Gut microbiota–brain axis in depression: The role of neuroinflammation. Eur J Neurosci. 2021;53(1):222–35. 10.1111/ejn.14631 . Kandpal M, Baral B, Varshney N, et al. Gut-brain axis interplay via STAT3 pathway: Implications of Helicobacter pylori derived secretome on inflammation and Alzheimer’s disease. Virulence. 2024;15(1):2303853. 10.1080/21505594.2024.2303853 . Choi YH, Lai J, Kim MA, et al. CagL polymorphisms between East Asian and Western Helicobacter pylori are associated with different abilities to induce IL-8 secretion. J Microbiol. 2021;59(8):763–70. 10.1007/s12275-021-1136-2 . Liu P, Liu Z, Wang J, et al. Immunoregulatory role of the gut microbiota in inflammatory depression. Nat Commun. 2024;15(1):3003. 10.1038/s41467-024-47273-w . Additional Declarations No competing interests reported. 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Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Huan","middleName":"","lastName":"Zhang","suffix":""},{"id":423851692,"identity":"9b653f1e-71f1-4481-b378-ee1e057fed39","order_by":2,"name":"Ju Zhang","email":"","orcid":"","institution":"The Fourth Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ju","middleName":"","lastName":"Zhang","suffix":""},{"id":423851694,"identity":"a2b556a3-ca06-4daa-81bf-753b2b9876dc","order_by":3,"name":"Nuo Yao","email":"","orcid":"","institution":"The Fourth Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Nuo","middleName":"","lastName":"Yao","suffix":""},{"id":423851698,"identity":"21416dfe-92a1-422e-a902-4ff62084dfb2","order_by":4,"name":"Zheyi Han","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYDACCSBObAASzAeARIWEnDzxWtgSgMQZC2PDBmK0MMK0MLZVJDIcIKBDfnbzMYmHO+zyGNi4UzfzzpNIYGxgfvjoBh4tjHOOpUkknkkuZmDj3Xabd5tEHjsDm7FxDh4tzBI5ZhKJbcyJDfK9YC3FjA08bNL4tLBJ5H8DaqlPbADbMkciseEAAS08EjlsQC2HoVoaiNAiIZFmbJHYdhys5eacYxLGhs0E/CI/I/nhzZ9t1WAtN97U1MnJszc/fIxPCxCwgKKGwf4AjM+MXzlYyQfCakbBKBgFo2BEAwC78kiWSGWuswAAAABJRU5ErkJggg==","orcid":"","institution":"Air Force Medical Center, The Fourth Military Medical University","correspondingAuthor":true,"prefix":"","firstName":"Zheyi","middleName":"","lastName":"Han","suffix":""},{"id":423851700,"identity":"544adac1-884d-448c-9241-fe6b473135a0","order_by":5,"name":"Yongquan Shi","email":"","orcid":"","institution":"The Fourth Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yongquan","middleName":"","lastName":"Shi","suffix":""}],"badges":[],"createdAt":"2025-03-02 14:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6139815/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6139815/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78240609,"identity":"467cfab2-0fca-45a2-8b07-dd5c458c2d2a","added_by":"auto","created_at":"2025-03-11 08:58:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":214516,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of population with low and moderate-high level stigma according to H. pylori infection status before (A) and after (B) PSM.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6139815/v1/2235875387db2797bc201703.png"},{"id":78241691,"identity":"ce13b2e8-62f2-431f-b418-bc60ede01ed1","added_by":"auto","created_at":"2025-03-11 09:06:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":228216,"visible":true,"origin":"","legend":"\u003cp\u003eThe relationship between H. pylori infection and stigma\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6139815/v1/ca3299d323bf6b3f28a30bf4.png"},{"id":78240618,"identity":"8746eac6-ca0f-4c58-8e36-d69b1c0d4dd5","added_by":"auto","created_at":"2025-03-11 08:58:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":90705,"visible":true,"origin":"","legend":"\u003cp\u003eThe mediating effect of anxiety symptom and depressive symptom on the relationship between H. pylori infection and stigma\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-6139815/v1/36286b849c502036994a8910.png"},{"id":78246513,"identity":"5b732136-8f43-43b7-8e2f-493d84636872","added_by":"auto","created_at":"2025-03-11 09:30:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1702262,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6139815/v1/7733035c-63c8-44f1-9f21-59a7d2988415.pdf"},{"id":78241679,"identity":"236140c6-8bea-44da-8102-6c293f7b3243","added_by":"auto","created_at":"2025-03-11 09:06:05","extension":"doc","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":794618,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile.doc","url":"https://assets-eu.researchsquare.com/files/rs-6139815/v1/b8e4a9da28c11c6a817e1e1b.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Associations of Helicobacter pylori infection with stigma and the mediating roles of anxiety and depression: a combination of cross-sectional and cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStigma is a multifaceted and hierarchical social process characterized by the attribution of labels, perpetuation of stereotypes, and implementation of segregation, resulting in the deprivation of status and discrimination, all within the framework of power dynamics \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. It negatively impacts individuals' well-being, hinders the implementation of psychosocial interventions, and affects health and social care services \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Additionally, disease-related stigma can also intensify patients' concerns and negative emotions, reducing treatment adherence and recovery \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. While most stigma research has concentrated on psychiatric disorders, infectious diseases and cancer \u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, the relationship between the common Helicobacter pylori (H. pylori) infection and stigma remains underexplored, compelling us to delve deeper into this area.\u003c/p\u003e \u003cp\u003eH. pylori, a highly infectious pathogen, infects over half of the global population, with an approximate 40% infection rate in our country \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Identified as a class I carcinogen \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, it is closely linked to gastric cancer development \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Given its contagious nature and association with cancer, H. pylori-infected patients may face stigma due to the public's fear and misunderstanding of cancer, leading to social exclusion or discrimination. Previous studies have found common psychiatric comorbidities like depression and anxiety in infected individuals \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, yet few directly examine the relationship between H. pylori infection and stigma. Therefore, This study aims to explore the stigma status and influencing factors in patients with H. pylori infection, providing new insights for their comprehensive management. By identifying the specific manifestations and impacts of stigma, we hope to offer practical guidance for clinicians to better support these patients and inform public health strategies to mitigate the stigma associated with H. pylori infection. This research not only fills a critical research gap but also advances theoretical frameworks and guiding future in-depth studies.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy participants\u003c/h2\u003e \u003cp\u003eThe single-center prospective study was conducted at a tertiary hospital in northwest China from October 2023 to July 2024. Using the Kendall sample size estimation method, with 60 observed variabkes, the planned sample size was 900 participants aged 18 to 60 who tested for H. pylori. Participants were excluded if they had cognitive impairment, epilepsy, psychiatric disorders, AIDS/HIV infection, leprosy, tuberculosis, physical disabilities, psoriasis or vitiligo skin conditions, inflammatory bowel disease, post-enterostomy complications, burns on exposed areas (face, neck, limbs), a history of substance abuse or addiction issues or were diagnosed with malignancy or severe organ dysfunction. The final sample size was 1144 participants (563 with H. pylori infection and 581 without), with the study protocol approved and written consent obtained from all participants.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eDemographic and disease-related questionnaire\u003c/h2\u003e \u003cp\u003eThe questionnaire encompassed the following domains: Demographics (gender, age, body mass index (BMI), education level, marital status, employment status, household income, self-assessed economic pressure, living status, smoking and drinking status ect), disease-related information (H. pylori infection status (No (never infected), Yes (previous or current infection)), disease course, H. pylori eradication treatment, co-morbidities, gastric mucosal lesions, knowledge and acceptance of H. pylori among self, family members, friends, and colleagues, support from healthcare workers, perceived health status, etc).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eSocial Impact Scale (SIS)\u003c/h3\u003e\n\u003cp\u003eThe SIS is a widely utilized generic stigma scale for assessing stigma in patients with infectious diseases and cancer \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. It includes 24 items across four dimensions: social rejection, financial insecurity, internalized shame and social isolation. The SIS items are rated on a scale from \"1\" (strongly disagree) to \"4\" (strongly agree), with total score ranging from 24 to 96. Higher score indicates more sever stigma. Based on the average score of each project, they are categorized three levels: low (1.00-1.99), moderate (2.00-2.99), and high (3.00\u0026ndash;4.00). The Chinese version of the SIS has demonstrated good psychometric properties, with a Cronbach's α 0.940.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eHospital Anxiety and Depression Scale (HADS)\u003c/h2\u003e \u003cp\u003eThe HADS consists of two subscales: the HADS-Anxiety Scale (HADS-A) and the HADS-Depression Scale (HADS-D) \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Each subscales contains seven items, rated on a scale from 0 to 3. The total score for each subscale ranges from 0 to 21, with higher scores indicating more severe anxiety or depressive symptoms.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe Gastrointestinal Symptom Rating Scale (GSRS)\u003c/h3\u003e\n\u003cp\u003eThe GSRS, authorized by its original author Svedlund, was used in this study to evaluated gastrointestinal symptoms \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. It includes 15 items categorized into 5 distinct symptom clusters: abdominal pain, reflux, diarrhea, dyspepsia, and constipation. Items are rated on a Likert-4 scale (0\u0026ndash;3), with a total score of 45 points. Higher scores indicate more severe symptoms.\u003c/p\u003e\n\u003ch3\u003eThe generic 12-item Short Form Health Survey (SF-12)\u003c/h3\u003e\n\u003cp\u003eThe SF-12 is a self-administered questionnaire designed to assess an individual's health status across eight dimensions: general health, physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. These dimensions are summarized into two subscales: Physical Component Summary (PCS) and Mental Component Summary (MCS). Each question offers two to five answer options, and a scoring algorithm is used to assess health status, with higher scores indicating better health.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eThe General Self-Efficacy Scale(GSES) and Social Support Rating Scale (SSRS)\u003c/h2\u003e \u003cp\u003eGSES \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e and SSRS \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e seach consist of 10 items, rated on a 4-point Likert scale ranging from 1 to 4. Higher scores on these scales indicate higher levels of self-efficacy and social support, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eSocio-demographic and clinical characteristics were described based on the H. pylori infection status at baseline. Continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median\u0026thinsp;\u0026plusmn;\u0026thinsp;interquartile range, and compared using independent two-sample t-tests or rank-sum tests. Categorical variables were assessed using the χ2 test and reported as percentages. Multiple linear regression analysis was used to investigate the relationship between H. pylori infection and stigma, and to identify the main factors affecting stigma in infected patients, based on significant intergroup differences found in univariate analysis and common demographic characteristics. Mediation analysis was conducted to explore the mediation effects of anxiety and depressive symptom on the relationship between H. pylori infection and stigma. Paired t-tests or paired rank sum tests were used to compare changes in SIS and SF-12 scores before and after treatment.\u003c/p\u003e \u003cp\u003eStatistical analyses were proformed using SPSS 25.0 and R 4.2.2 software, with a significance level was set at 0.05 (two-tailed test).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics of study participants\u003c/h2\u003e \u003cp\u003eA total of 1144 participants, comprising 563 with H. pylori infection and 581 without, were recruited. The baseline characteristics by infection status are detailed in supplementary file table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e. Patients with infection exhibited higher rates of disease duration exceeding one year, family infected, ulceration, gastric intestinal metaplasia, and intraepithelial neoplasia. They also showed greater awareness and acceptance of H. pylori infection among themselves as well as their social circles. Notably, the inflection group has significantly higher anxiety and depression scores, as well as higher SIS and subscale scores, while the incidence of functional gastrointestinal disorders and gastroesophageal reflux were lower compared to the control group (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eA revealed that patients with H. pylori infection had a higher rate of moderate-to-severe stigma at 24.69% compared to 9.81% for without infection. Following propensity score matching (PSM) (1:1) to balance the statistically different demographic and disease characteristics between the two groups, a cohort of 504 participants was selected, evenly split between infected and non-infected individuals (252 each). Post-matching, no differences in demographic and disease characteristics were observed between the groups, as detailed in supplementary file table S2. Despite this, patients with H. pylori infection continued to show a higher rate of moderate-to-severe stigma at 20.24% versus 7.94% for the non-infected group, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eB.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThe relationship between Helicobacter pylori infection and stigma\u003c/h2\u003e \u003cp\u003eThe relationship between H. pylori infection and stigma is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The multivariate linear regression analysis indicated that H. pylori infection is an independent predicted of stigma levels (β 5.38, 95%CI 3.83\u0026ndash;6.94, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and is also positively associated with SIS subscale scores, as shown in supplementary file table S3. In subgroup analyses, we assessed the correlation between H. pylori infection and stigma across various demographic and clinical factor, including age (\u0026lt;\u0026thinsp;45 and 45\u0026ndash;60), gender (male and female), BMI (\u0026lt;\u0026thinsp;24 and \u0026ge;\u0026thinsp;24), education level (\u0026le;\u0026thinsp;high scholl and \u0026gt;\u0026thinsp;high scholl), marital status (other and married), employment status (unemployed and employed), perceived economic stress (low, middle, and high), disease duration (\u0026le;\u0026thinsp;1 and \u0026gt;\u0026thinsp;1), and perceived health status (bad, general, and good). H. pylori infection was closely link to stigma in these subgroups, with a significant interaction only in the perceived economic pressure subgroup (P-interaction\u0026thinsp;=\u0026thinsp;0.025). No significant interactions were found in the other subgroups (P-interaction\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with stigma among patients with Helicobacter pylori infection\u003c/h2\u003e \u003cp\u003eUnivariate analysis identified several facters significantly associated with stigma amomg patients with H. pylori infection, including family income, perceived economic stress, drinking status, living status, number of treatments received, acceptance from family, friends and colleagues regarding H. pylori infection, seeking psychological help, perceived health status, gastrointestinal symptoms, degree of anxiety and depression, self-efficacy, and physical and mental health (all p values\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Multivariate linear regression analysis further revealed that age, seeking psychological help, receiving treatment for H. pylori infection and anxiety were positively associated with stigma. In constrast, higher income level, greater self-efficacy, physical health and mental health were negatively associated with stigma (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Additionally, 258 patients who underwent eradication therapy were followed up, with 186 patients completing a follow-up questionnaire again. Paired rank sum test indicated that post-treatment, SIS score and subscale scores, as well as anxiety and depression scores, and gastrointestinal symptoms scores decreased, while quality of life subscale scores increased (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\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\u003eFactors influencing stigma among patients with H. pylori infection\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\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 \u003cdiv align=\"left\" 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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eUnadjusted model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c13\" namest=\"c9\"\u003e \u003cp\u003eAdjusted model\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS.E\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eβ (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eS.E\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eβ (95%CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.770\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.01 (-0.08\u0026thinsp;~\u0026thinsp;0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.12 (0.01\u0026thinsp;~\u0026thinsp;0.22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGSRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.57 (0.32\u0026thinsp;~\u0026thinsp;0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.699\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-0.05 (-0.28\u0026thinsp;~\u0026thinsp;0.19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGSES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-9.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.81 (-0.98 ~ -0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-0.27 (-0.45 ~ -0.09)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.50 (-0.66 ~ -0.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-0.23 (-0.40 ~ -0.06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-12.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.57 (-0.66 ~ -0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-4.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-0.25 (-0.36 ~ -0.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.89 (1.62\u0026thinsp;~\u0026thinsp;2.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e5.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.02 (0.63\u0026thinsp;~\u0026thinsp;1.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.74 (1.42\u0026thinsp;~\u0026thinsp;2.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.715\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.08 (-0.33\u0026thinsp;~\u0026thinsp;0.48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily income, n(%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\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=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2000\u0026ndash;7999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-7.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-7.51 (-13.63 ~ -1.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-6.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-6.46 (-11.69 ~ -1.24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;8000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-9.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-9.49 (-15.42 ~ -3.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-7.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-7.80 (-13.13 ~ -2.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived economic pressures, n(%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.59 (2.15\u0026thinsp;~\u0026thinsp;7.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.38 (-0.79\u0026thinsp;~\u0026thinsp;3.55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.22 (2.11\u0026thinsp;~\u0026thinsp;8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2.24 (-0.54\u0026thinsp;~\u0026thinsp;5.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrinker, n(%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrinker\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-drinker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.58 (-0.33\u0026thinsp;~\u0026thinsp;5.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.739\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.48 (-2.36\u0026thinsp;~\u0026thinsp;3.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEx-drinker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.61 (1.30\u0026thinsp;~\u0026thinsp;11.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e4.45 (-0.73\u0026thinsp;~\u0026thinsp;9.63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCure\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\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=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00 (Reference)\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=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.28 (-0.60\u0026thinsp;~\u0026thinsp;9.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e4.25 (0.12\u0026thinsp;~\u0026thinsp;8.38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of treatments, n(%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.98 (-0.35\u0026thinsp;~\u0026thinsp;4.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.846\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-0.21 (-2.35\u0026thinsp;~\u0026thinsp;1.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.22 (0.74\u0026thinsp;~\u0026thinsp;7.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.602\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.85 (-2.33\u0026thinsp;~\u0026thinsp;4.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.80 (-1.15\u0026thinsp;~\u0026thinsp;6.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-1.28 (-5.01\u0026thinsp;~\u0026thinsp;2.44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptance level\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily, n(%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1.99 (-5.27\u0026thinsp;~\u0026thinsp;1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.77 (-7.38\u0026thinsp;~\u0026thinsp;10.93)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-3.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-3.41 (-6.26 ~ -0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-0.59 (-7.77\u0026thinsp;~\u0026thinsp;6.58)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFriends and colleagues, n(%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.22 (-5.52\u0026thinsp;~\u0026thinsp;1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-5.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-5.55 (-14.80\u0026thinsp;~\u0026thinsp;3.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-3.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-3.74 (-6.58 ~ -0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-2.79 (-9.88\u0026thinsp;~\u0026thinsp;4.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeel mental services helpful\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.73 (7.33\u0026thinsp;~\u0026thinsp;20.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e7.71 (2.22\u0026thinsp;~\u0026thinsp;13.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived health status, n(%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBad\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-9.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-9.34 (-12.69 ~ -5.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-1.77 (-5.05\u0026thinsp;~\u0026thinsp;1.51)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-14.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-7.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-14.39 (-17.92 ~ -10.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-2.49 (-6.33\u0026thinsp;~\u0026thinsp;1.36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDwelling status, n(%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLive alone\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLive with spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-6.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-6.13 (-10.71 ~ -1.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-3.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-3.54 (-7.70\u0026thinsp;~\u0026thinsp;0.62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-4.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-4.18 (-8.09 ~ -0.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-1.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-2.91 (-6.46\u0026thinsp;~\u0026thinsp;0.63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastric disease, n(%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic non-atrophic gastritis\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic atrophic gastritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.88 (-0.88\u0026thinsp;~\u0026thinsp;4.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.74 (-0.63\u0026thinsp;~\u0026thinsp;4.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntestinal metaplasia and dysplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.12 (-1.56\u0026thinsp;~\u0026thinsp;7.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.27 (-3.87\u0026thinsp;~\u0026thinsp;4.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUlceration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.435\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.04 (-7.17\u0026thinsp;~\u0026thinsp;3.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.25 (-4.07\u0026thinsp;~\u0026thinsp;4.57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.734\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.49 (-2.32\u0026thinsp;~\u0026thinsp;3.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e3.17 (0.66\u0026thinsp;~\u0026thinsp;5.68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"13\" nameend=\"c13\" namest=\"c1\"\u003e \u003cp\u003eCI: Confidence Interval\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=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePaired rank sum compared the total stigma score and its subscale scores, anxiety and depression scores, and gastrointestinal symptoms scores and the quality of life subscale scores before and after treatment.\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=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.00 (26.00, 48.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.00 (24.00, 27.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-9.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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\u003eSocial rejection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.00 (9.00, 17.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.00 (9.00, 9.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-9.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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\u003eFinancial insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.00 (3.00, 6.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.00(3.00,4.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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\u003eInternalized shame\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.00 (5.00, 13.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.00 (5.00, 5.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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\u003eSocial isolation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.00 (7.00, 14.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.00 (7.00, 8.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-8.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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\u003eHADS A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.00 (1.00, 6.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00 (0.00, 1.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-8.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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\u003eHADS D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.00 (3.00, 7.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00 (1.00, 3.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-9.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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\u003eSF12\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=\"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\u003ePCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.29 (42.60, 48.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.98 (44.98, 48.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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\u003eMCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.67 (45.28, 57.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.17 (51.40, 62.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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\u003eGSRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.00 (3.00, 8.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00 (0.00, 1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\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=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eMediation of the association between Helicobacter pylori infection and stigma through anxiety and depressive symptom\u003c/h2\u003e \u003cp\u003eSupplementary file table S4 indicated that, after adjusting for all confounding factors, H. pylori infection was positively correlated with anxiety symptom (β\u0026thinsp;\u0026plusmn;\u0026thinsp;SE\u0026thinsp;=\u0026thinsp;0.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21, p\u0026thinsp;=\u0026thinsp;0.003) and depressive symptom (β\u0026thinsp;\u0026plusmn;\u0026thinsp;SE\u0026thinsp;=\u0026thinsp;0.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, both anxiety and depressive symptom were significantly associated with stigma (β\u0026thinsp;\u0026plusmn;\u0026thinsp;SE\u0026thinsp;=\u0026thinsp;1.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; β\u0026thinsp;\u0026plusmn;\u0026thinsp;SE\u0026thinsp;=\u0026thinsp;0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Supplementary file table S5). Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e illustrated that anxiety and depressive symptom mediated the relationship between H. pylori infection and stigma. Specifically, for H. pylori infection, anxiety symptom and depressive symptom mediated 13.37% and 9.90% of the indirect effects on stigma, respectively.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, individuals with H. pylori-infected exhibited higher stigma compared to those without infection. Additionally, we also found an independent association between H. pylori infection and stigma, with anxiety and depressive symptom partially mediating this association. Further analysis in patients with H. pylori infection revealed that age, seeking psychological help, receiving treatment for H. pylori infection, as well as anxiety symptom were positively associated with stigma. Conversely, higher income level, greater self-efficacy, and better physical and mental health were negative association with stigma. Additionlly, eradication therapy reduced the stigma experienced by infected patients.\u003c/p\u003e \u003cp\u003eH. pylori gastritis has been officially recognized as an infectious disease in the 2015 Kyoto Global Consensus Report on Helicobacter pylori \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Numerous studies have consistently shown the stigma is prevalent among patients with various infectious diseases. Indeed, a meta-analysis involving 92,722 participants showed that approximately 38% of patients with infectious diseases such as atypical pneumonia, influenza A (H1N1), Middle East respiratory syndrome, Zika virus disease, Ebola virus disease, and COVID-19 experienced stigma \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Similarly, among sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), genital herpes, syphilis, viral hepatitis, gonorrhoea, vaginal trichomoniasis, and pubic pediculosis, some people are reluctant to disclose disclose their STIs, Even when notified of a positive test result, they may delay testing, refuse to seek treatment, and fail to inform their partners \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Furthermore, stigma is also common among patients with leprosy and tuberculosis \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. However, there is a lack of epidemiological surveys describing the incidence of stigma in patients with H. pylori infection.\u003c/p\u003e \u003cp\u003eIn this study, among 1144 patients, the median total stigma score was 30, and 17.13% of the participants experienced moderate-high levels of stigma. The H. pylori infection group had a higher total stigma score compared to the control group. Similarly, previous studies have reported stigma in patients with certain malignant tumors, such as lung cancer \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, breast cancer \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and head and neck neoplasms \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Likewise, stigma is also prevalent in infection-related malignancies including cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers caused by human papillomavirus \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, Leukemia and lymphoma due to HTLV \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, and HIV -related malignancies like Kaposi's sarcoma \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Furtherore, H. pylori is recognized as a class I carcinogenic factor for gastric cancer by the International Agency for Research on Cancer and is closely link to gastric adenocarcinoma development \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Thus, consistent with these findings, our study showed that a greater proportion of patients with H. pylori infection experienced moderate-to-high levels of stigma compared with the control group. This suggest that while stigma levels in patients with H. pylori infection are generally lower than in those with malignant tumors, a significant number still face moderate-high stigma.\u003c/p\u003e \u003cp\u003eMany demographic, disease-related, and psychosocial factors are associated with stigma in patients with infectious diseases or cancer \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Similarly, consistent with findings that higher income is associated with lower stigma in cancer patients \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e, our study found that higher incom is associated with lower stigma in patients with H. pylori infection. This may be because higher income can significantly reduce the psychological and financial stress caused by disease diagnosis and treatment. Conversely, while previous studies have shown that higher education levels reduces stigma in cancer and infectious diseases \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e, we did not find a significant association between education level and stigma in H. pylori infection, similar to findings by James et al \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Moreover, the relationship between age and stigma is inconsistent across studies. Some show a negatively associated in lung cancer \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e and breast cancer \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e, while age is a risk factor for stigma in Crohn's disease \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e, mirroring our results. This may be due to decreased work ability and income with age, increasing the financial and care burden on families. Additionally, we found that anxiety symptoms were independently associated with stigma in patients with H. pylori infection, consistent with evidence in tuberculosis and HIV-Positive patients \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePrevious studies have demonstrated a positive association between H. pylori infection and anxiety and the development of depression across various populations \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Moreover, H. pylori infection has been shown to increased anxiety and depressive behaviors in mouse models \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Notably, in our mediation analysis, anxiety and depressive symptom were found to partially mediate the relationship between H. pylori infection and stigma. These findings suggest that H. pylori infection may promote the onset of anxiety symptom and depressive symptom, thereby increasing the stigma experienced by patients with H. pylori infection, thus revealing potential mechanisms. Prior research has implicated the microbiota-gut-brain axis in the pathogenesis of various diseases \u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e, including disorders of the gastrointestinal system \u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e and psychiatric conditions \u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. The gastrointestinal (GI) tract is considered a sensory organ that transmits information to the brain, playing a crucial role in detecting, transmitting, integrating, and responding to signals from both internal and external environments, thereby influencing behavior and emotions \u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. The gut microbiota is essential for facilitating bidirectional communication between the gastrointestinal tract and the central nervous system. H. pylori infection can modulate the composition of gut microbiota and impact the physiological state of the gut-brain axis (GBA) \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Furthermore, the presence of H. pylori can modulate the level of inflammation in the body \u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. In the cellular experiment, H. pylori strains co-cultured with neurons and neuron-astrocytes have been shown to increase reactive oxygen species (ROS) production and inflammatory response within these cells \u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Additionally, some studies have found that H. pylori can induce the release of pro-inflammatory cytokines, such as interleukin (IL) -8, from gastric epithelial cells \u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. These inflammatory cytokines can have a significant effect on GBA activity \u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe strength of this study lies in the use of 13/14C-UBT and gastric mucosal biopsy as diagnostic markers for H. pylori infection, which offer near 100% specificity and sensitivity. However, our study has limitations. Firstly, being a cross-sectional study, it cannot establish causal relationships. Secondly, although we adjusted for may potential confounders, some relevant factors may remain unaccounted for. third, The study's results may be influenced by traditional Chinese culture; so caution is needed when applying these findings to other populations. This study is an initial exploreation of the stigma experienced by patient with H. pylori infection, highlighting the need for future studies with larger sample sizes and longitudinal designs to further investigate this phenomenon.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study shown that H. pylori infection is an independent risk factor for stigma, with 24.69% of patients with H. pylori infected experiencing moderate-high levels of stigma. Facters influencing stigma in these patients included age, income, receiving treatment, seeking psychological help, anxiety symptom, self-efficacy, and physical and mental health. Therefore, medical professionals should closely monitor the stigma levels in patients with H. pylori infection who are older, have lower family income and self-efficacy, and present with anxiety.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eH. pylori\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHelicobacter pylori\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial Impact Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGSRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGastrointestinal Systemic Response Score Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHADS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHospital Anxiety and Depression Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHADS-A\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHADS-Anxiety Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHADS-D\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHADS-Depression Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSF-12\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eShort Form Health Survey 12\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhysical Component Summary\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMental Component Summary\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGSES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Self-efficacy Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSSRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial Support Rating Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003ein accordance with the Declaration of Helsinki, the study was approved by the Ethics Committee of Xijing Hospital (KY20242348). All participants provided informed written consent at enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Written informed consent was obtained from the patient for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003eAll data of the study are presented in the text or supplementary materials.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement:\u0026nbsp;\u003c/strong\u003eThis work was supported by grants from Shaanxi Key Research Innovation \u0026amp; Development Project (No. 2023-ZDLSF-35).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization and design, Z.H., Y.S.; methodology, J.Y., software, J.Z.; formal analysis, J.Y., H.Z., and N.Y.; data curation, J.Y.; draft, J.Y.; review and editing, J.Y.; supervision, Y.S., and Z.H. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e We sincerely appreciate the staff and participants for making invaluable efforts and contributions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNyblade L, Stockton MA, Giger K, et al. Stigma in health facilities: why it matters and how we can change it. BMC Med. 2019;17(1):25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12916-019-1256-2\u003c/span\u003e\u003cspan address=\"10.1186/s12916-019-1256-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThornicroft G. 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Nat Commun. 2024;15(1):3003. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41467-024-47273-w\u003c/span\u003e\u003cspan address=\"10.1038/s41467-024-47273-w\" 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":"Stigma, Helicobacter pylori, Depression, Anxiety, Mediation models","lastPublishedDoi":"10.21203/rs.3.rs-6139815/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6139815/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eStigma is common in certain infectious diseases and infection-related cancer. Helicobacter pylori (H. pylori) is infectious and related to gastric cancer. However, little is known about the relationship between H. pylori infection and stigma. Therefore, our study aims to investigate stigma and its influencing factors among patients with H. pylori infection.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003e1144 participants were recruited from a tertiary hospital in northwest China from October 2023 to July 2024. The research instruments comprised Social Impact Scale, Gastrointestinal Systemic Response Score Scale, Hospital Anxiety and Depression Scale, Short Form Health Survey 12, General Self-efficacy Scale and Social Support Rating Scale. Multiple linear regression analysis was conducted to examine the relationship between H. pylori infection and stigma, as well as influencing factors of stigma in infected patients. Mediation models were used to evaluate whether anxiety and depression mediate the relationship between H. pylori infection and stigma.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCompared to non-infected patients, those with H. pylori infection had higher total stigma scores (34 vs 27 points, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a larger proportion of moderate-severe stigma (24.69% vs 9.81%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). H. pylori infection was positively correlated with stigma (β 5.38, 95%CI 3.83\u0026ndash;6.94, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with anxiety symptom and depressive symptom mediating 13.37% and 9.90% of this correlation, respectively. In H. pylori-infection patients, age, seeking psychological help, receiving treatment and anxiety symptoms were positively correlated with stigma, while higher income, self-efficacy and quality of life were negatively correlated.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eH. pylori-related stigma is common among infected patients. Therefore, routine stigma assessment, professional mental health support, counseling services, and public education are recommended to reduce stigma in this subpopulation.\u003c/p\u003e","manuscriptTitle":"Associations of Helicobacter pylori infection with stigma and the mediating roles of anxiety and depression: a combination of cross-sectional and cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-11 08:58:00","doi":"10.21203/rs.3.rs-6139815/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":"65301e96-5794-45f8-b183-01bcb8870a55","owner":[],"postedDate":"March 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-17T14:53:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-11 08:58:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6139815","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6139815","identity":"rs-6139815","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}