Abstract
Currently, there is no questionnaire to assess perceived stigmatization among people with visible differences in Brazil. The Perceived Stigmatization Questionnaire (PSQ), developed in the United States, is a valid instrument to assess the perception of stigmatizing behaviours among burn survivors. The objective of this cross-sectional and multicentre study was to assess the factor structure, reliability and validity of the Brazilian Portuguese version of the PSQ in burn patients. A Brazilian version of the 21-item PSQ was answered by 240 adult burn patients, undergoing rehabilitation in two burns units in Brazil. We tested its construct validity by correlating PSQ scores with depression (Beck Depression Index-BDI) and self-esteem (Rosenberg Self-Esteem Scale-RSE), as well as with two domains of the Revised Burn Specific Health Scale—BSHS-R: affect and body image, and interpersonal relationships. We used Confirmatory Item Factor Analysis (CIFA) to test whether the data fit a measurement model involving a three-factor structure (absence of friendly behaviour; confusing/staring behaviour; and hostile behaviour). We conducted Exploratory Factor Analyses (EFA) of the subscale in a 50% random sample of individuals (training split), treating items as ordinal categorical using unweighted least squares estimation. To assess discriminant validity of the Brazilian version of the PSQ we correlated PSQ scores with known groups (sex, total body surface area burned, and visibility of the scars) and assessed its reliability by means of Cronbach's alpha and using test-retest. Goodness-of-fit indices for confirmatory factor analysis were satisfactory for the PSQ, but not for the hostile behaviour subscale, which was modified to improve fit by eliminating 3 items. Cronbach’s alphas for the PSQ refined version (PSQ-R) ranged from 0.65 to 0.88, with test-retest reliability 0.87 for the total score. The PSQ-R scores correlated strongly with depression (0.63; p < 0.001), self-esteem (-0.57; p < 0.001), body image (-0.63; p < 0.001), and interpersonal relationships (-0.55; p < 0.001). PSQ-R total scores were significantly lower for patients with visible scars (effect size = 0.51, p = 0.029). The PSQ-R showed reliability and validity comparable to the original version. However, the cross-cultural structure of the subscale “hostile behaviour” and sensitivity to change of the PSQ should be further evaluated.
Highlights
That some people may develop psychopathology due to the visible result of a physical injury is well known [1]
A recent systematic review of patient-reported outcome measures (PROMs) administered to burn survivors [13] has found that the Perceived Stigmatization Questionnaire (PSQ) and the Social Comfort Questionnaire (SCQ) are the only two generic PROMs which have been psychometrically evaluated among both child and adult burn survivors [4,14]
Because the absolute fit was not achieved, we considered approximate fit using Root Mean Square Error of Approximation (RMSEA) 0.08; and relative fit using Comparative Fit Index (CFI) ! 0.95 and Tucker-Lewis Index (TLI) ! 0.95 [30], and overall residual considered acceptable if the Weighted Root Mean Residual (WRMR) < 0.95 [31, 32]
Summary
That some people may develop psychopathology due to the visible result of a physical injury is well known [1]. People with visible differences, such as those resulting from a burn injury, frequently report perceiving stigmatizing behaviour in others, such as staring, comments and questions [3], bullying, avoidance behaviour, teasing and external pressure to change their appearance [4]. Such stigmatization behaviours may lead these individuals to experience further feelings of social discomfort, social anxiety, distress, poor body image and low self-esteem, resulting in social isolation [5,6]. The following factors: scar visibility, body surface area burned- BSA (BSA
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