Quality of life (QoL) among COVID-19 recovered healthcare workers in Bangladesh

Post COVID-19 infection and quality of life of healthcare workers at Sahloul University Hospital of Sousse in Tunisia

BACKGROUND

Since the COVID-19 pandemic, health care workers (HCWs) faced an enormous physical and mental burden, sometimes altering their quality of life due mainly to persistent challenges stemming from their frontline position.

AIMS

Todetermine the prevalence of post-COVID-19 syndrome, and its impact on the Health-Related Quality of Life (HRQoL) among HCWs.

METHODS

This is an exhaustive cross-sectional study with analytical scope, conducted among all HCWs of the University Hospital Sahloul of Sousse, Tunisia, who have contracted COVID-19 between September 2020 and 30 March 2021 (N=529 cases).The post-covid medical check-up was carried out three months after the acute phase of the COVID-19 infection (December 2020 to June 2021). HRQoL was assessed using the SF-12 (12-item Short Form Health Survey) questionnaire. Bivariate study and multiple linear regressions were performed to identify the different factors influencing the quality of life of HCWs.

RESULTS

During the study period, 529 HCWs were diagnosed with SARS CoV-2 infection, out of them 249 participants were included (47% participation rate). Post covid-19 syndrome was reported in 65% of cases. A low overall quality of life (QoL) score was reported in 28.6% of cases. Low physical and mental composite scores were reported in 34.3% and 29.4% of cases respectively. In the multiple linear regression analysis, gender, post COVID-19 syndrome and time off work were significantly associated with SF12 scores.

CONCLUSION

In our study, HCWs experienced a significant deterioration in HRQoL after COVID-19 with a high incidence of post-COVID-19 syndrome. The need of long-term follow-up after SARS-CoV-2 infection remains essential to support HCWs and mitigate long-term impacts.

Gender difference in domain-specific quality of life measured by modified WHOQoL-BREF questionnaire and their associated factors among older adults in a rural district in Bangladesh

BACKGROUND

The global population of older adults has steadily increased in recent decades. Little is known about the gender difference in the quality of life (QoL) of older adults in the general population. This study aimed to identify factors associated with QoL among older adults by gender.

METHOD

Data on QoL using the World Health Organization Quality of Life (WHOQoL-BREF) questionnaire and socio-demographic characteristics, including living status and sources of income, were collected from 1147 older adults. The WHOQoL-BREF has four domains: physical, psychological, social and environmental. Rasch analysis was used to compute a combined score from Likert-type data to a continuous scale ranging from 0% satisfaction to 100% satisfaction in terms of QoL for each domain. We used a generalized linear model to compare the mean rate of QoL for different factors, and logistic regression analysis was used to quantify the associations of factors with below-average QoL measured as 50% or less in QoL.

RESULTS

The domain-specific QoL mean (standard error), minimum-maximum values were physical 48.9 (0.41), 7-86, psychological 38.9 (0.51), 4-71, social 50.5 (0.49), 8-92, and environmental domains 47.8 (0.37), 6-91 in the total sample with significant gender difference in all but social domain. The proportion of below average QoL for females vs. males was physical 47.6% vs. 42.6%, psychological 74.4% vs.66.7%; social 34.8% vs. 30.1% and environmental domains 56.1% vs. 49.0%. In females, participants living alone were associated with a higher proportion of below average QoL in physical OR 30.2, 95% CI 2.47, 370, psychological OR 9.54, 95% CI1.09,83.27 and social domains OR 5.94, 95% CI 1.25,28.34. In males, participants' sources of income from relatives were associated with a higher proportion of below average QoL in physical OR 3.6, 95% CI 2.01,6.44, psychological 30.2, 95% CI 2.47, 370, psychological OR 4.63 95% CI 2.56, 8.38, social domains OR 1.81, 95% CI 1.04, 3.16 and environmental domains OR 2.53 95% CI 1.44, 4.43 than those who had own income. Females engaged in income generation activities had better QoL in social and environmental domains than those with house duties, irrespective of their education or socioeconomic status. Males in retired life had the highest QoL in the social and environmental domains if they had better SES.

CONCLUSIONS

The study's findings reveal that more than 50% of people had below-average QoL in each domain, which is significant. The study also highlighted that females living alone and males without their own income had the poorest QoL. On a positive note, it was found that females engaged in any income generation activities had better QoL in social and environmental domains. These results provide valuable insights for policymakers and healthcare professionals. They underscore the importance of implementing appropriate intervention programs to enhance the QoL of older adults, reiterating the urgency and necessity of their work to improve the health and well-being of older adults.

Post-COVID in healthcare workers and its consequences on quality of life, activities, participation, need for rehabilitation and care experiences: protocol of a cohort study

INTRODUCTION

Healthcare workers (HCWs) have been of particular relevance for overcoming the SARS-CoV-2 pandemic. At the same time they have been affected by SARS-CoV-2 infections with above average probability. Around 6.5% of the overall infected persons are likely to develop persistent symptoms resulting from the infection, known as long-COVID or post-COVID syndrome (PCS). The aim of this study is (1) to investigate the prevalence, course and characteristics of PCS in German HCWs, (2) to examine its effects on psychosocial variables, (3) to identify rehabilitation and healthcare needs and (4) to analyse treatment experiences.

METHODS AND ANALYSIS

In a cohort study with a randomised selection of participants (N=20 000) from the Employer's Liability Insurance Association for Health and Welfare Care, the health status of HCWs, who had COVID-19 in their professional context will be examined. There will be two measurement points: baseline (T1) and a 12-month follow-up (T2). The outcome measures are the health status with a particular focus on persistent or newly occurring symptoms after a SARS-CoV-2 infection, health-related quality of life, functional capacity, the subjective need for and utilisation of healthcare services. Pre-existing conditions, the course of the acute infection and sociodemographic factors are considered as predictors. An advisory board made up of affected HCWs supports the study by contributing to the surveys' contents.

ETHICS AND DISSEMINATION

The study has been approved by the Local Ethics Committee of the Center for Psychosocial Medicine at the University Hospital Hamburg-Eppendorf (LPEK-0518). For dissemination, the results will be published in peer-reviewed journals, presented at conferences and communicated to relevant stakeholders in general and rehabilitation medicine.

TRAIL REGISTRATION NUMBER

https://drks.de/search/de/trial/DRKS00029314.

Clinical presentation of post-COVID pain and its impact on quality of life in long COVID patients: a cross-sectional household survey of SARS-CoV-2 cases in Bangladesh

BACKGROUND

Pain is one of the prevalent Long COVID Symptoms (LCS). Pain interferes with the quality of life (QoL) and induces disease burden.

PURPOSE

The study aimed to elicit the clinical presentation of pain and determine the relationships between QoL and pain in LCS.

METHODS

This household cross-sectional study of 12,925 SARS-CoV-2 cases between July and December 2021 was carried out in eight administrative divisions of Bangladesh. Stratified random sampling from the cases retrieved from the Ministry of Health was employed. Symptom screening was performed through COVID-19 Yorkshire Rehabilitation Scale, and long COVID was diagnosed according to World Health Organization (WHO) criteria. The analyses were conducted using IBM SPSS (Version 20.00).

RESULTS

The prevalence of pain in long COVID was between 01 and 3.1% in the studied population. The study also found five categories of pain symptoms as LCS in Bangladesh: muscle pain 3.1% (95% CI; 2.4-3.8), chest pain 2.4% (95% CI; 1.8-3.1), joint pain 2.8% (95% CI; 2.2-2.3), headache 3.1% (95% CI; 2.4-3.8), and abdominal pain 0.3% (95% CI; 0.01-0.5). People with LCS as pain, multiple LCS, and longer duration of LCS had significantly lower quality of life across all domains of the WHOQOL-BREF (P < 0.001) compared to asymptomatic cases.

CONCLUSION

Three out of ten people with long COVID experience painful symptoms, which can significantly reduce their quality of life. Comprehensive rehabilitation can improve the symptoms and reduce the burden of the disease.

Factors associated with cognitive impairment and the quality-of-life among COVID-19 survivors working as healthcare workers

Prolonged physical and mental health changes, known as post-COVID conditions (PCC), could impair the quality-of-life (QoL) of healthcare workers. The aim of this study was to identify factors that contribute to cognitive impairments and QoL among COVID-19 survivors working as healthcare workers. This cross-sectional study involved healthcare workers at Prof. Dr. Chairuddin P. Lubis Universitas Sumatera Utara Hospital, Medan, Indonesia. The Montreal Cognitive Assessment (MoCA) was used to assess the cognitive function, while the World Health Organization Quality-of-Life Brief Version (WHOQOL-BREF) questionnaire was used to evaluate the QoL. Factors associated with cognitive and QoL status were examined using Mann-Whitney and Chi-squared tests. A total of 100 COVID-19 survivors were included in the study, most of whom were female (74%), aged ≤35 years (95%), and were doctors (62%). Only 22% of the participants had a normal BMI, 93% had a history of mild COVID-19, and 54% had one comorbidity. The Overall MoCA score averaged 24.18±2.86, indicating mild cognitive impairment among the groups. The distribution of MoCA scores had similar patterns with no significant differences based on age, gender, comorbidities, BMI, COVID-19 severity, and frequency of COVID-19 infection. Interestingly, the number of vaccine doses received by the participants had a statistically significant associated with MoCA scores of which those receiving more than two doses had higher cognitive scores than those with only two doses (p=0.008). Based on categorized MoCA scores (normal vs cognitive impairment), none assessed factors were not significantly associated with cognitive outcomes. The WHOQOL-BREF scores ranged from 62.5 to 95.5, with a mean±SD of 83.67±7.03. None of the assessed factors were associated with WHOQOL-BREF scores among COVID-19 survivors. These findings highlight the need for further study to explore the protective role of vaccination frequency in cognitive impairment and the factors underlying the resilience in QoL among survivors.

Long-Term Quality of Life after COVID-19 Infection: Cross-Sectional Study of Health Care Workers

(1) Background: Post-COVID syndrome is defined as symptoms that occur simultaneously with or after a COVID-19 infection, last for 12 weeks, and are not due to another diagnosis. Limited data are available on people's long-term quality of life following a COVID-19 infection. The aim of this cross-sectional study was to investigate the long-term quality of life after COVID-19 among employees of a hospital in Germany and to identify risk factors. (2) Methods: A monocentric, cross-sectional study was conducted using the validated and digitized WHOQOL-BREF questionnaire via Netigate® between 10/2022 and 02/2023. Data on the quality of life and global health status were collected in the following four domains: physical health, mental health, social relationships, and the environment. (3) Results: The response rate was 73.8 % (923/1250). Furthermore, 63.4 % of the hospital staff respondents reported at least one persistent symptom after a COVID-19 infection, leading to significant differences in quality of life. Pre-existing conditions, persistent symptoms, and disabilities after a COVID-19 infection as well as a high BMI, no partnership, and a low educational level were found to significantly contribute to a low long-term quality of life. (4) Conclusions: Obesity, a lack of partnership, and a low level of education were independent risk factors for a lower quality of life post-COVID-19 infection in this cohort of hospital staff. Further multicenter studies are required to validate the incidence and their suitability as independent risk factors for post-COVID syndrome.

Psychological repercussions of COVID-19 on health care workers, Sudan

Healthcare workers around the world were confronted with innumerable torments with the emergence of COVID-19. Amid the pandemic, frontline healthcare personnel serve crucial responsibilities and endure significant social, psychological and economic consequences. This cross-sectional study collected demographic data for 1 year from 385 healthcare officials from all the hospitals spread across the state of Khartoum to research the factors that affected the healthcare workers and doctors who were on the frontline to diagnose and treat the patients with potential or confirmed COVID-19. The degree of symptoms of depression, anxiety and insomnia was also assessed through validated measurement tools. The female participants showed more vulnerability to depression, anxiety and insomnia than their male counterparts. It was reported by the end of the study that the healthcare workers in Sudan are under immense psychological hazards.

Quality of life of COVID-19 recovered patients: a 1-year follow-up study from Bangladesh

BACKGROUND

The COVID-19 pandemic posed a danger to global public health because of the unprecedented physical, mental, social, and environmental impact affecting quality of life (QoL). The study aimed to find the changes in QoL among COVID-19 recovered individuals and explore the determinants of change more than 1 year after recovery in low-resource settings.

METHODS

COVID-19 patients from all eight divisions of Bangladesh who were confirmed positive by reverse transcription-polymerase chain reaction from June 2020 to November 2020 and who subsequently recovered were followed up twice, once immediately after recovery and again 1 year after the first follow-up. The follow-up study was conducted from November 2021 to January 2022 among 2438 individuals using the World Health Organization Quality of Life Brief Version (WHOQOL-BREF). After excluding 48 deaths, 95 were rejected to participate, 618 were inaccessible, and there were 45 cases of incomplete data. Descriptive statistics, paired-sample analyses, generalized estimating equation (GEE) analysis, and multivariable logistic regression analyses were performed to test the mean difference in participants' QoL scores between the two interviews.

RESULTS

Most participants (n = 1710, 70.1%) were male, and one-fourth (24.4%) were older than 46. The average physical domain score decreased significantly from baseline to follow-up, and the average scores in psychological, social, and environmental domains increased significantly at follow-up (P < 0.05). By the GEE equation approach, after adjusting for other factors, we found that older age groups (P < 0.001), being female (P < 0.001), having hospital admission during COVID-19 illness (P < 0.001), and having three or more chronic diseases (P < 0.001), were significantly associated with lower physical and psychological QoL scores. Higher age and female sex [adjusted odd ratio (aOR) = 1.3, 95% confidence interval (CI) 1.0-1.6] were associated with reduced social domain scores on multivariable logistic regression analysis. Urban or semi-urban people were 49% less likely (aOR = 0.5, 95% CI 0.4-0.7) and 32% less likely (aOR = 0.7, 95% CI 0.5-0.9) to have a reduced QoL score in the psychological domain and the social domain respectively, than rural people. Higher-income people were more likely to experience a decrease in QoL scores in physical, psychological, social, and environmental domains. Married people were 1.8 times more likely (aOR = 1.8, 95% CI 1.3-2.4) to have a decreased social QoL score. In the second interview, people admitted to hospitals during their COVID-19 infection showed a 1.3 times higher chance (aOR = 1.3, 95% CI 1.1-1.6) of a decreased environmental QoL score. Almost 13% of participants developed one or more chronic diseases between the first and second interviews. Moreover, 7.9% suffered from reinfection by COVID-19 during this 1-year time.

CONCLUSIONS

The present study found that the QoL of COVID-19 recovered people improved 1 year after recovery, particularly in psychological, social, and environmental domains. However, age, sex, the severity of COVID-19, smoking habits, and comorbidities were significantly negatively associated with QoL. Events of reinfection and the emergence of chronic disease were independent determinants of the decline in QoL scores in psychological, social, and physical domains, respectively. Strong policies to prevent and minimize smoking must be implemented in Bangladesh, and we must monitor and manage chronic diseases in people who have recovered from COVID-19.

Impact of COVID-19 pandemic on the health-related quality of life of frontline workers: the case of seven low-income Eastern African countries

PURPOSE

This study aimed to explore the potential impact of the COVID-19 pandemic on the health-related quality of life (HRQoL) of humanitarian and healthcare workers and its related factors in seven Eastern African countries (EAC).

METHODS

A sample of frontline workers filled out an online cross-sectional survey questionnaire comprising socio-demographic, degree of symptoms of depression, anxiety, insomnia, and distress, alcohol and tobacco consumption, health-related quality of life (HRQoL) using Short Form 6-Dimension version 2 (SF-6Dv2) and Clinical Outcomes in Routine Evaluation 6-Dimension (CORE-6D), and fear of COVID-19 (FCV-19S) questionnaires. Multivariate regressions were conducted to identify independent factors associated with HRQoL.

RESULTS

Of total 721 study participants, mean (standard deviation) scores for SF-6Dv2 and CORE-6D were 0.87 (0.18) and 0.81 (0.14), respectively. Participants with an education level below a university degree, having chronic diseases, been tested positive to COVID-19, with traumatic memories, depression, insomnia, distress, and stress were found to have lower HRQoL likelihood in terms of SF-6Dv2 scores during the COVID-19 pandemic. Similarly, participants with chronic diseases, exposure to COVID-19 patients, depression, insomnia, distress, stress, tested positive with COVID-19, and high level of fear of COVID-19, had lower HRQoL likelihood in terms of CORE-6D scores. Participants who were married had higher HRQoL likelihoods in terms of SF-6Dv2 scores.

CONCLUSION

Some personal and mental health characteristics, and COVID-19 related factors, were predictors of lower HRQoL of frontline workers in EAC. These findings should be meaningful while designing sustainable interventions and guidelines aiming to improve the HRQoL of frontline workers during a pandemic situation.

Quality of Life in Healthcare Workers during COVID-19-A Longitudinal Study

The COVID-19 pandemic occurred in 2020, and affected people's daily life worldwide at work and at home. Healthcare workers are a professional group with heavy workloads, and during the COVID-19 pandemic, their burden increased. The literature from earlier outbreaks describes risks for affected mental health in frontline workers, and the main aim of this study is to examine healthcare workers' quality of life during the COVID-19 pandemic. In addition, we sought to assess if there was any difference in working at a pandemic ward compared to anon-pandemic ward. In this longitudinal and descriptive study, a total of 147 healthcare workers assessed their perceived health every third month over one year using the RAND-36 health survey. RAND-36 is a general instrument that consists of 36 questions and is widely used for assessing quality of life. The healthcare workers in this study showed reductions in perceived quality of life during the first six months of the COVID-19 pandemic. Healthcare workers on a pandemic ward reported a lower score in RAND-36 compared to healthcare workers on a non-pandemic ward. Registered nurses and licensed practical nurses seemed more negatively affected in their quality of life than physicians. Compared to data from the general Swedish population, healthcare workers in this study had less energy during this period.

Post-COVID Quality of Life and Sleep Among Younger Healthcare Workers of Designated COVID Care Centers: A Cross-Sectional Study

Introduction Frontline healthcare workers (FLHCWs) have been persuaded to work this coronavirus disease (COVID) pandemic way in and out but the pandemic has not subsided. The persistence of symptoms after COVID infection, especially chest symptoms like early fatigue with breathlessness, has been documented very well. However, FLHCWs have repeatedly caught the COVID infection and have been working in traumatic and helpless situations since the pandemic started. Post-COVID infection, quality of life (QOL) and sleep are greatly affected, regardless of the time elapsed since discharge or recovery. The continuous assessment of COVID-infected persons for post-COVID sequelae is an important and effective step to reduce complications. Materials and methods This was a cross-sectional study conducted for a period of one year at R.L. Jalappa Hospital and Research Center, Kolar, and SNR District Hospital, Kolar, which were designated COVID care centers. FLHCWs working in these centers who had contracted COVID infection at least once, who were more than 18 years and less than 30 years, and who had experience of less than five years irrespective of their vaccination status were included in the study. FLHCWs with COVID-related health illnesses, which needed ICU admission and prolonged hospital admission, were excluded. To assess QOL, the WHO Quality of Life Brief Version (WHOQOL-BREF) questionnaire was used. To assess sleepiness, the Epworth daytime sleepiness scale was used. The study was started after the institutional ethical committee's clearance was obtained. Results A total of 201 healthcare workers (HCWs) completed the survey. Of the participants, 119 (59.2%) were male, 107 (53.2%) were junior residents, 134 (66.7%) were unmarried, and 171 (85.1%) said they followed regular shifts. Male HCWs had higher scores in the psychological, social relationship, and environmental domains of QoL. Consultants had higher scores in all domains of QoL. Married HCWs had higher scores in the physical, psychological, and social relationship domains of QoL. Out of 201 FLHCWs, 67 (33.3%) had moderate excessive daytime sleep, and 25 (12.4%) had severe excessive daytime sleep. Few factors like gender, occupation, duration of work in the hospital, and regular shifts were statistically significant factors associated with daytime sleepiness. Conclusion The present study has shown that even after the COVID vaccination doses received by the HCWs, sleep and Qol have still been impaired among infected younger healthcare staff. Acceptable and righteous efforts must be made by the institutions for proper policymaking to manage such infectious outbreaks in the future.

Association between proximity to COVID-19 and the quality of life of healthcare workers

Background

The coronavirus disease 2019 (COVID-19) affects almost all countries in the world and it impacts every aspect of people’s life-physically, mentally, and socio-economically. There are several research studies examining the impact of this pandemic on health, however, very few studies examining the impact of this pandemic on quality of life. This study aimed to investigate the association between proximity to the COVID-19 and quality of life of healthcare workers and identify factors influencing quality of life.

Methods

A cross-sectional study was conducted among hospital staff in a tertiary hospital in Singapore. Data on demographic, medical history, lifestyle factors, psychosocial factors, and quality of life were collected using online self-administered questionnaire. Quality of life (QoL) was measured by the WHOQOL-BREF questionnaire. Robust linear regression was used to determine factors associated with quality of life.

Results

A total of 1911 participants were included in the analysis. The average age of participants was 38.25 (SD = 11.28) years old. 26.90% of participants had been quarantined, hospitalised, being suspected or diagnosed of having COVID-19 infection and they were found to have the lowest levels of QoL across all four domains (physical, psychological, social, and environmental domains). Participants who were singles or nurses, worked in shifts or worked longer hours, had chronic diseases were likely to have lower QoL scores compared to participants in other categories. Healthy lifestyle, social connectivity, resilience, social and workplace support were associated with higher QoL scores.

Conclusions

In planning of measures which aim to improve QoL of healthcare workers, priority should be given to individuals who have been quarantined, hospitalised, being suspected, or diagnosed of having COVID-19 infection. In addition to the proximity of the COVID, lifestyle and psychosocial factors contribute to QoL of healthcare workers. Hence, multifaceted interventions are needed to improve QoL of healthcare workers.

Demographic and work-related factors associated with burnout, resilience, and quality of life among healthcare workers during the COVID-19 pandemic: A cross sectional study from Malaysia

Introduction

The healthcare setting is a stressful and demanding work environment, and healthcare workers face a continuous expansion of their job roles and responsibilities. Past studies have shown that factors affecting burnout, resilience, and quality of life among healthcare workers merit further research, as there were inconsistent findings, especially with regards to the influence of demographic and work-related factors. Therefore, this study aims to determine whether demographic and work-related factors are associated with burnout, resilience, and quality of life among healthcare workers.

Method

This cross-sectional study was conducted between February 15, 2022 and March 15, 2022, among 394 healthcare workers from Putrajaya and Selangor hospitals, Malaysia. Maslach Burnout Inventory, World Health Organization Quality of Life-BREF 26 inventory, and Brief Resilience Scale were utilized to capture information on burnout, quality of life, and resilience, respectively.

Results

The mean score of physical health of participants who work more than 10 h (11.38) is lower than participants who work from 8 to 10 h (13.00) and participants who work 7 h daily (13.03), p-value < 0.001. Similarly, the mean score of psychological health of participants who work more than 10 h (12.35) is lower than participants who work from 8 to 10 h (13.72) and participants who work 7 h daily (13.68), p-value = 0.001. Higher income levels were associated with high resilience and quality of life.

Conclusion

It is imperative that healthcare practitioners and policy makers adopt and implement interventions to promote a healthy workplace environment, address ethical concerns, and prevent burnout among healthcare workers during the COVID-19 pandemic. Managing the issue of long working hours could possibly result in improved resilience, burnout, and quality of life among healthcare workers. Despite this study able to tickle out some policy specific areas where interventions are needed, identifying effective solutions and evaluating their efficiency will require larger and interventional studies.

"The whole sky has broken down on me. I might die alone": A qualitative study on the lived experiences of COVID-19 positive frontline workers in Bangladesh

Many countries, including Bangladesh, have conducted research on the mental health of frontline workers and their challenges in adjusting to their new workplaces. However, the authors are unaware of any studies on their real-life experiences as COVID-19-positive patients in Bangladesh. This study intends to investigate the lived experiences of Bangladeshi frontline workers who were isolated as a result of the COVID-19 infection and tested positive for the virus. We used a qualitative methodology and a semi-structured interview guide to conduct ten interviews between July 26 and August 12, 2020. The participants were recruited via a social media campaign and purposive sampling. All interviews were conducted via telephone and online and were transcribed and analyzed using Colaizzi's phenomenological method. The study does, however, identify four primary themes and 13 supporting themes, including (1) experience in a new working environment (subthemes: workload and adaptation, maintaining health protocol and social distance, and the fear of infection), (2) diagnosis (subthemes: the origin of infection, physiological problems, experiences at the diagnosis center), (3) recovery days (subthemes: earlier reactions, experiences in isolation, coping mechanisms), and (4) post-COVID-19 (subthemes: excitement, fear, and confusion; physiological problems; increased religiosity; and changes in philosophy). This study is important for healthcare policymakers because it helps them design healthcare management systems that take Bangladeshi society's social context into account. This study also recommends that long-term behavioral change programs be implemented by national policymakers to lessen societal stigma. At the same time, it suggests that the government should help lessen the barriers to health care services that persons with lower socioeconomic status confront.