The experience of stigma related to hearing loss and hearing aids: perspectives of adults with hearing loss, their families, and hearing care professionals.

OBJECTIVES: To explore when and how stigma-induced identity threat is experienced by adults with hearing loss (HL) and their family members (affiliate stigma) from the perspectives of adults with HL, their family members, and hearing care professionals. DESIGN: Qualitative descriptive methodology with semi-structured interviews. STUDY SAMPLE: Adults with acquired HL (n = 20), their nominated family members (n = 20), and hearing care professionals (n = 25). RESULTS: All groups of participants believed that both HL and hearing aids were associated with stigma for adults with HL. Two themes were identified, specifically: (1) an association between HL and hearing aids and the stereotypes of ageing, disability, and difference; and (2) varied views on the existence and experience of stigma for adults with HL. Hearing care professionals focused on the stigma of hearing aids more than HL, whereas adult participants focused on stigma of HL. Family member data indicated that they experienced little affiliate stigma. CONCLUSIONS: Stigma-induced identity threat related to HL and, to a lesser extent, hearing aids exists for adults with HL. Shared perceptions that associate HL and hearing aids with ageing stereotypes were reported to contribute to the identity threat, as were some situational cues and personal characteristics.

Relationship between affiliate stigma and family quality of life among parents of children with autism spectrum disorders: The mediating role of parenting self-efficacy.

BACKGROUND: The parents of children with autism spectrum disorder (ASD) are under great pressure and experience discrimination in their daily lives, which affects their family quality of life (FQOL). OBJECTIVE: METHODS: A total of 237 parents of children with ASD were recruited in a university-affiliated hospital in Guangzhou, China, from October 2020 to April 2021 by convenience sampling. The Affiliate Stigma Scale, Parenting Sense of Competence Scale and Beach Center Family Quality of Life Scale were employed for data collection. RESULTS: The results showed that affiliate stigma negatively predicts total FQOL and the dimensions of FQOL through both a direct effect and an indirect effect through parenting self-efficacy. CONCLUSIONS: The findings suggest that affiliate stigma is an important predictor of FQOL, and interventions to reduce affiliate stigma and strengthen parenting self-efficacy might be effective in improving FQOL in the parents of children with ASD.

Quality of life among family caregivers of people with schizophrenia in rural China.

PURPOSES: To investigate quality of life (QoL) of family caregivers of people with schizophrenia and examine the influencing factors of the QoL in a Chinese rural area. METHODS: This study included people with schizophrenia (n = 269) and their family caregivers (n = 269) from Xinjin district, Chengdu, China. Family caregivers' QoL was measured by the World Health Organization Quality of Life-Brief Form and its influencing factors was analyzed by the multivariate regression. RESULTS: Family caregivers of people with schizophrenia had very poor QoL across four domains. The regression analysis showed that physical domain of QoL was significantly associated with age, psychiatric symptoms of people with schizophrenia, and caregiving burden of family caregivers (p < 0.05). Psychological domain of QoL was significantly related to family caregivers' affiliate stigma, caregiving burden, and psychiatric symptoms of people with schizophrenia (p < 0.05). Social domain of QoL was significantly associated with age and psychiatric symptoms of people with schizophrenia, and affiliate stigma of family caregivers (p < 0.05). Environmental domain of QoL was significantly related to age and psychiatric symptoms of people with schizophrenia, and family caregivers' caregiving burden (p < 0.05). CONCLUSION: Family caregivers of people with schizophrenia had poor QoL in rural China. Family caregivers' QoL is significantly impacted by age and psychiatric symptoms of people with schizophrenia, caregivers' affiliate stigma and caregiving burden. Providing social support and psychosocial interventions for family caregivers of people with schizophrenia might be crucial to improve their QoL and caregiving.

Examining the association between neuropsychiatric symptoms among people with dementia and caregiver mental health: are caregiver burden and affiliate stigma mediators?

BACKGROUND: Neuropsychiatric disturbances are common manifestations of dementia disorders and are associated with caregiver burden and affiliate stigma. The present study investigated affiliate stigma and caregiver burden as mediators for the association between neuropsychiatric symptoms of people with dementia (PWD) and caregiver mental health such as depression and anxiety. METHODS: A cross-sectional survey study was carried out with 261 dyads of PWD and informal caregivers from the outpatient department of a general hospital in Taiwan. The survey included the Caregiver Burden Inventory (CBI), the Affiliate Stigma Scale (ASS), the Taiwanese Depression Questionnaire (TPQ), and the Beck Anxiety Inventory (BAI). Mediation models were tested using the Hayes' PROCESS macro (Model 4 for parallel mediation model; Model 6 for sequentially mediation model). RESULTS: Caregiver burden, affiliate stigma, caregiver depression, and caregiver anxiety were significantly associated with neuropsychiatric symptoms. After controlling for several potentially confounding variables, it was found that PWD's neuropsychiatric symptoms, caregiver burden and affiliate stigma significantly explained 52.34% of the variance in caregiver depression and 37.72% of the variance in caregiver anxiety. The parallel mediation model indicated a significantly indirect path from PWD's neuropsychiatric symptoms to caregiver mental health through caregiver burden and affiliate stigma, while the direct effect was not significant. Moreover, there was a directional association between caregiver burden and affiliate stigma in the sequential mediation model. CONCLUSIONS: These findings show that it is imperative to improve caregivers' perception of those with dementia to reduce internalized stigma and to improve caregivers' mental health. Implementation of affiliate stigma assessment in clinical practice would allow distinctions to be made between the impact of affiliate stigma and the consequences of caregiver burden to help inform appropriate intervention.

Changes in family functioning among primary family caregivers of patients with schizophrenia.

INTRODUCTION: Family functioning, particularly among primary family caregivers for patients with schizophrenia, is a global concern that poses unprecedented challenges. The family unit is a pivotal agent for the preservation of the integrity of individual members. Little attention has been paid to the changes in family functioning and their predictors in primary family caregivers. This study aimed to examine the changes in and the correlates of family functioning in primary family caregivers of individuals with schizophrenia over a 6-month post-discharge period. DESIGN: A prospective, longitudinal study was conducted. METHODS: A total of 58 primary family caregivers of patients with schizophrenia were recruited from two psychiatric hospitals in Taiwan. Data were collected four times, including 1 week before hospital discharge and at 1-, 3-, and 6-month intervals post-discharge. Demographic and clinical questionnaires, the Affiliate Stigma Scale, the Family Empowerment Scale, and the General Functioning subscale were used to collect data. Generalized Estimating Equations were applied for data analysis. RESULTS: Approximately 59.6%-77.6% of primary family caregivers presented unhealthy family functioning during the 6-month post-discharge period. Significant reductions in family functioning of primary family caregivers were noted in the group with unhealthy family functioning; however, family functioning of primary family caregivers remained unchanged in the group with healthy family functioning over 6 months. Affiliate stigma and family empowerment significantly accounted for the changes in family functioning of primary family caregivers in the groups with unhealthy and healthy family functioning, respectively. CONCLUSION: This study highlights affiliate stigma and family empowerment as long-term predictors of changes in family functioning for primary family caregivers and as pivotal targets of mental health care. CLINICAL RELEVANCE: Family-centered interventions with a focus on ameliorating affiliate stigma and enhancing family empowerment are recommended to improve family functioning for primary family caregivers of patients with schizophrenia at different periods after hospital discharge.

To tell or not to tell? Exploring the social process of stigma for adults with hearing loss and their families: introduction to the special issue.

OBJECTIVE: Stigma has long been implicated as a reason why adults with acquired hearing loss are slow to seek help and for sub-optimal uptake of hearing devices. However, the field has not developed a comprehensive understanding of why stigma occurs, nor has it related this comprehensive knowledge to a theoretical framework. DESIGN: This special issue presents results from a two-phase, multi-method study to systematically investigate how stigma is experienced by adults with hearing loss and their families, how they manage it in everyday life, and how these experiences relate to the decision to wear hearing aids. STUDY SAMPLE: Phase 1 of the study involved 20 dyads of adults with hearing loss and their family members. Phase 2 involved 331 adults with hearing loss and 313 family members. RESULTS: Results of the study are presented in each of the subsequent papers that are part of this special issue. Results are mapped onto the Major and O'Brien model of stigma-induced identity threat in each paper. CONCLUSIONS: This paper provides an introduction to the Special Issue and describes the methods for the overall study that is the focus of the papers within the issue.

Hopelessness in caregivers of children with attention-deficit/hyperactivity disorder: Associations with depression and anxiety and multidimensionally related factors.

BACKGROUND/PURPOSE: Hopelessness can compromise caregivers' mental health and impede their ability to take care of their child with attention-deficit/hyperactivity disorder (ADHD). The study aimed to explore the associations of hopelessness with caregiver depression and anxiety in caregivers of children with attention-deficit/hyperactivity disorder (ADHD). Additionally, the study examined the associations of child demographics, ADHD and oppositional defiance symptoms, and caregiver demographics, parenting stress, and affiliate stigma with hopelessness. METHODS: The study included 213 caregivers of children with ADHD who completed various assessments. Caregiver hopelessness was assessed using the Beck Hopelessness Scale, while child ADHD and oppositional defiance symptoms were assessed using the Parent Form of the Swanson, Nolan, and Pelham Scale, Version IV. Parenting stress was measured using the Parenting Stress Index, Fourth Edition Short Form (PSI-4-SF), and affiliate stigma using the Affiliate Stigma Scale. Hierarchical regression analysis was used to investigate the multidimensional factors associated with caregiver hopelessness. RESULTS: Caregiver hopelessness was significantly linked to caregiver depression and anxiety. Child inattention, caregiver parenting stress, and affiliate stigma were significantly associated with caregiver hopelessness. A higher level of affiliate stigma increased the association between child inattention and caregiver hopelessness. CONCLUSION: These findings suggest that it is necessary to develop intervention programs for alleviating the sense of hopelessness among caregivers of children with ADHD. Such programs should focus on addressing child inattention, caregiver parenting stress, and affiliate stigma.

Self-esteem and family functioning mediates the association of symptom severity and parental affiliate stigma among families with children with ASD.

PURPOSE: To investigate the level of affiliate stigma among parents of children with autism spectrum disorder and to explore the mediating role of self-esteem and family functioning. DESIGN AND METHODS: A cross-sectional study was conducted in a large regional hospital and two childhood rehabilitation centers in Guangdong, China. Data related to demographics, parental self-esteem, family functioning, and affiliate stigma were collected from 180 parents of children diagnosed with ASD. We used t-tests, analysis of variance, and correlation analysis to explore the related factors of parental affiliate stigma. Path analysis was used to determine the mediating roles of self-esteem and family functioning in the relationship between symptom severity and affiliate stigma. RESULTS: Parents of children with autism spectrum disorder in China experienced low self-esteem, family functioning, and high affiliate stigma. Symptom severity was negatively correlated with self-esteem and family functioning. Self-esteem and family functioning were significantly negatively correlated with affiliate stigma. Symptom severity was positively correlated with affiliate stigma. Self-esteem and family functioning mediated the relationship between symptom severity and affiliate stigma. CONCLUSIONS: Symptom severity affects parental affiliate stigma among families with children with ASD. Self-esteem and family functioning are the two mediators in the relationship. We should take steps to improve self-esteem and family functioning in order to alleviate parental affiliate stigma. PRACTICE IMPLICATIONS: This study emphasizes the importance of the influence of ASD severity and family functioning on affiliate stigma. In clinical practice, psychological support should be provided for parents of children with ASD to improve their mental health.

Autistic children's age difference in affiliate stigma and resilience of their parents in China: A cross-sectional study.

BACKGROUND: Parents of children with Autism Spectrum Disorders (ASD) experience high levels of stigma, especially in China where the culture is shame socialized. Resilience can help overcome stigma; while parent characteristics predict resilience, other factors may also be significant such as the child's age. OBJECTIVE: The study sought to identify the differences in affiliate stigma and resilience among Chinese parents of children with ASD according to the child's age, and to determine whether the levels of resilience and experience of stigma are related. METHODS: A cross-sectional survey of 184 parents of children with ASD was conducted. Affiliate stigma and resilience were measured using the Chinese version of the 22-item Affiliate Stigma Scale and the Chinese version of the Connor-Davidson Resilience Scale. Differences were examined by using regression and correlation analysis. RESULTS: Parents of school-age children experienced more affiliate stigma than parents of preschoolers, but there was no difference in resilience when other factors were controlled. CONCLUSIONS: Considering the child's age is important to understand affiliate stigma and resilience, particularly where resilience is protective and could inform the design of support strategies for preschooler parents.

A brief measure of perceived courtesy and affiliate stigma on COVID-19: A study with a sample from China.

The present study aimed to assist public health efforts by developing and conducting psychometric testing of a brief measure of COVID-19-related stigma among people who were potentially but not necessarily infected. All the items were generated and selected based on extensive literature review, participant interviews, and expert evaluations. The psychometric properties were evaluated through performing confirmatory factor analysis tests, exploration structure equation modeling, measurement invariance, internal consistency coefficient, composite reliability, and criterion-related validity, using a sample of 2812 adults (600 male, 2212 female; mean age = 37.23, SD = 6.17) from Hubei Province, China. A clear two-factor structure of the COVID-19-related stigma among people who were potentially but not necessarily infected (i.e., perceived courtesy and affiliate stigma) was identified through the literature review and interviews. Results suggest that the two-factor model of COVID-19-related stigma (5 items for each factor) model fit the data, and the psychometric properties were acceptable. Measurement invariance across gender was supported. A two-factor 10-item scale was finally obtained.

Who internalizes courtesy stigma and how? A study among Israeli Arab family caregivers of persons with dementia.

Objectives: The expected rise in the number of persons with dementia is accompanied by an increasing interest in understanding and reducing the stigmatic beliefs experienced by family caregivers of persons with the disease. While researchers have recently distinguished between family caregivers' perceptions of public stereotypes (i.e., courtesy stigma) and the internalization of these perceptions (i.e., affiliate stigma), no study has yet assessed the characteristics of dementia caregivers who internalize courtesy stigma and how they do so. The aim of this study was to examine the characteristics of family caregivers of persons with dementia who internalize courtesy stigma, and to investigate this internalization process.Method: Structured face-to-face interviews were conducted with 175 Israeli Arab family caregivers (87.4% female; 71.4% adult children; mean age = 54.28) for persons with Alzheimer's disease.Results: Overall, half of the participants reported experiencing affiliate stigma as a result of taking care of a relative with dementia. Regression analyses showed that lower educational level, increased courtesy stigma and lower levels of social support were the main predictors of affiliate stigma. Social support partially mediated the association between courtesy and affiliate stigma.Conclusion: Our findings provide important insights for the conceptual understanding and the development of interventions to reduce stigma among family caregivers of persons with dementia.

Parents' Experiences of Affiliate Stigma when Caring for a Child with Autism Spectrum Disorder (ASD): A Meta-Synthesis of Qualitative Studies.

PROBLEM: Stigma affects not only children diagnosed with autism spectrum disorder (ASD) themselves, but also people connected with them (i.e., parents, siblings). The capacity of parents to provide care is affected by the stigma they perceive. This meta-synthesis encompasses the experiences of affiliate stigma among parents of children with ASD. ELIGIBILITY CRITERIA: Articles were limited to the English language, those reported on stigma experienced by parents of children with ASD aged 2-18 years, published between 1940 and 2019. SAMPLE: PubMed, CINAHL, PsycINFO, EMBASE, Scopus and The Cochrane Library databases were searched for eligible studies. Titles and abstracts were reviewed, and twelve articles fitted the selection criteria. The texts of the selected research papers were reviewed by two independent reviewers. RESULTS: Four common themes across parental experiences included felt stigma, enacted stigma, variations in stigma, and contributors to stigmatizing experiences. CONCLUSIONS: Highlighting the differences in parents' views on affiliate stigma is necessary to create awareness about ASD and the stigma linked with this disorder. IMPLICATIONS: The findings asserted that healthcare professionals, especially those in pediatric settings, and society need to have a greater awareness of the stigma and challenges that these parents encounter as this has implications on their mental and physical health. This awareness will lead to more compassionate health care delivery which will support them and create a better environment for families and children with ASD.

Affiliate stigma, perceived social support and perceived stress in caregivers of children with autism spectrum disorder: A multiple mediation study.

BACKGROUND: Affiliate stigma negatively predicts social support, and positively predicts psychological distress, in caregivers of children with ASD. Whether the affiliate stigma-distress relationship occurs indirectly via social support however has not been explored. METHODS: A correlational design was used. A sample of n = 124 caregivers of children with ASD completed an online survey assessing affiliate stigma, perceived support from family, friends and significant others, and perceived stress. RESULTS: The relationship between greater affiliate stigma and increased perceived stress occurred indirectly via lower perceived support from family, but not from friends or significant others. CONCLUSIONS: These findings underscore the importance of increasing caregivers' perceived family support. Whether interventions that alleviate affiliate stigma are beneficial for reducing perceived stress, and whether this effect is mediated by increased perceived availability of support, might be the subject of future research.

The role of mothers' affiliate stigma and child's symptoms on the distress of mothers with ADHD children.

BACKGROUND: Mothers of ADHD children often display high levels of distress. Understanding the origin of such distress in a view to reducing it is an essential part of the clinical management of ADHD children. Studies have shown that children's symptoms are linked to mothers' stigma and that such stigma can cause mothers' distress. However, no study has explored the links between symptoms, stigma and distress. AIM: We tested (1) whether children's symptoms are sources of affiliate stigma, which in turn contributes to generating mothers' distress and (2) whether such relationship is stronger in mothers of male ADHD children. METHOD: 159 French mothers of an ADHD child were recruited. Four indices were used to assess mothers' distress: anxiety, depression, self-esteem and life satisfaction. Children's ADHD symptoms and mothers' affiliate stigma were also measured and contrasted with distress. RESULTS: Mothers' distress was positively related with both affiliate stigma and children's ADHD symptoms, but this was only true in mothers of male ADHD children. The relationship between children's symptoms and mothers' distress was mediated by affiliate stigma. CONCLUSIONS: Psychosocial interventions in mothers of ADHD children must integrate affiliate stigma and should be adjusted according to child's gender.

Affiliate stigma and caregiver burden in intractable epilepsy.

Intractable epilepsy can be challenging for patients and for their families. Disability rates in patients are high, causing tremendous physical and emotional burden on family caregivers. Additionally, caregivers may experience affiliate stigma, where they perceive and internalize the negative societal views of a condition and exhibit a psychological response. Affiliate stigma has been rarely studied in caregivers of those with intractable epilepsy. This study examined the relationship between affiliate stigma and the levels of burden experienced by caregivers, as well as how these levels may vary between those caring for children and adults. This cross-sectional approach used a self-administered survey offered to caregivers of family members with confirmed diagnoses of intractable epilepsy. We measured burden with the 30-item Carer's Assessment of Difficulties Index (CADI) and affiliate stigma with a six-item scale examining caregivers' perceptions of stigma directed toward themselves and their family members with epilepsy. Four nested ordinary-least-squares regression models were estimated using stigma scale scores to predict levels of perceived burden adjusting for demographic variables. Age of the patient with epilepsy was dichotomized (pediatric/adult) to assess a possible moderating effect of patient's age on the relationship between stigma and caregiver burden. Respondents (N = 136) were predominantly White (83%), female (75%), and married (69%), with an average age of 43 years. Patients with epilepsy were 52% male with ages ranging from 2 to 82 years. Each of the regression models yielded positive associations (p < 0.001) between perceived levels of caregiver burden and affiliate stigma. Additionally, the age of the family member with epilepsy moderated (p < 0.05) the effect, with the relationship stronger for caregivers of adults. In a highly select group of patients with refractory epilepsy recruited mostly from a cannabidiol (CBD) clinic, this study demonstrated that caregivers experience affiliate stigma, which is significantly associated with higher burden levels. Additionally, this study identified specific needs, which when met, may improve caregivers' physical and mental health.

Validation of the Malay Version of the Affiliate Stigma Scale among Caregivers of Patients with Mental Illness.

BACKGROUND: Caregivers of patients with mental illness are exposed to stigma. The internalisation of this stigma among caregivers is known as affiliate stigma and can be measured by the Affiliate Stigma Scale (ASS). The aim of this study was to validate the Malay version of the ASS. METHODS: A cross-sectional study was performed from May to December 2017 with 372 caregivers of patients with mental illness. The ASS was first translated into Malay using standard forward and backward translation procedures. The final version of the ASS-Malay (ASS-M) was completed by participants. The data analyses involved assessment of construct validity by exploratory factor analysis, confirmatory factor analysis and construct reliability. RESULTS: The final model of the ASS-M consists of four factors with 21 items, as compared to the original version, which has three factors with 22 items. The results showed that the final model has good model fit based on RMSEA (0.065) and SRMR (0.055) and a satisfactory composite reliability (affective = 0.827, cognitive = 0.857, behaviour = 0.764, self-esteem = 0.861). CONCLUSION: The study showed that the four-factor, 21-item ASS-M model has good psychometric properties. The scale is valid and reliable for measuring affiliate stigma among caregivers of patients with mental illness in Malaysia.

Living with schizophrenia: Health-related quality of life among primary family caregivers.

AIMS AND OBJECTIVES: To examine influencing factors of health-related quality of life in primary family caregivers of people with schizophrenia receiving inpatient psychiatric rehabilitation services. BACKGROUND: Families, particularly primary family caregivers, have become more important than ever in mental health care. Yet, research on health-related quality of life among primarily family caregivers is limited. DESIGN: A correlational study design was used. METHODS: A convenience sample of 122 primary family caregivers participated in the study. Data were analysed with descriptive statistics, Pearson's product-moment correlation, t test, one-way analysis of variance and a hierarchical multiple regression analysis. RESULTS: Primary family caregivers who were parents, older, less educated, and had a lower monthly household income, increased affiliate stigma and decreased quality of family-centred care experienced poor health-related quality of life. Particularly, monthly household income, affiliate stigma and quality of family-centred care appeared to be the most critical determinants of health-related quality of life. CONCLUSIONS: Efforts to enhance satisfaction of life should focus on reducing affiliate stigma as well as increasing monthly household income and strengthening the quality of family-centred care. RELEVANCE TO CLINICAL PRACTICE: Findings may assist in the development of culturally integrated rehabilitation programmes to decrease affiliate stigma and increase family engagement as a means of promoting quality of life for primary family caregivers living with people who have schizophrenia.

The Impact of Affiliate Stigma on the Psychological Well-Being of Mothers of Children with Specific Learning Disabilities in India: The Mediating Role of Subjective Burden.

BACKGROUND: Knowledge of the impact of affiliate stigma on the wellbeing of caregivers to children with specific learning disability (SLD) in India is limited. To fill in this gap in knowledge a cross-sectional quantitative study was undertaken to assess the impact of affiliate stigma on the psychological well-being of mothers with children with SLD in India, and test the mediating role of subjective burden, using an adapted version of Pearlin's stress and adaptation model. METHODS: Sample included 100 mothers of children with SLD. Data was collected using a structured interview schedule. Descriptive statistics, correlation and stepwise regression were used as the primary analytic tools. RESULTS: Affiliate stigma experienced by mothers significantly predicted low levels of psychological well-being and subjective burden mediated the relationship between affiliate stigma and psychological wellbeing. CONCLUSIONS: The findings call for developing targeted interventions to address affiliate stigma and positive appraisal of the caregiving situation, with the goal of improving the psychological well-being of mothers of children with SLD.

[Self-Awareness of Disease Stigma: Reflections of Healthcare Professionals].

People who suffer from disease frequently experience disease-related stigmas. Stigma presents in daily life during normal human interactions. The stereotypes promoted by the media often impact public opinion significantly. Moreover, healthcare professionals may exacerbate stigmatization due to their misunderstanding of patients and their disease issues. Therefore, the reflection on stigma of healthcare professionals cannot be ignored. The present article illustrates the issue of stigmas held by healthcare professionals, their related stigmas, and their self-awareness. It is hoped that all healthcare professionals may cooperate to develop an anti-stigma strategy and to become true spokespersons for their patients.

Self-stigma and affiliate stigma in first-episode psychosis patients and their caregivers.

PURPOSE: Stigma is a major factor causing delayed help-seeking and poor treatment adherence in patients with psychotic disorders. Previous research has mostly focused on chronic samples and the impact of culturally-relevant variables on both patients' and their caregivers' stigmatization is understudied. This study aimed to examine the relationships between various forms of stigma, "face concern", and clinical characteristics in a group of Chinese first-episode psychosis (FEP) patients and their caregivers. METHODS: Forty-four Hong Kong Chinese aged 15-54 years presenting with FEP to psychiatric services and their caregivers were recruited. Assessments on self-stigma, affiliate stigma, perceived public stigma, "face concern", symptom severity and subjective quality of life (QoL) were conducted. RESULTS: Self-stigma of FEP patients was correlated with perceived public stigma, "face concern", insight and psychological health of QoL. Multiple regression analysis revealed that perceived public stigma and "face concern" independently predicted self-stigma. Mediation analysis further suggested that "face concern" partially mediated the relationship between perceived public stigma and self-stigma. Caregivers' affiliate stigma was significantly associated with higher levels of stress, and symptoms of depression and anxiety. Affiliate stigma did not correlate with perceived public stigma and "face concern". CONCLUSION: Our results indicate a critical role of perceived public stigma and fear of losing face in determining self-stigma in Chinese patients with FEP. Caregivers with greater degree of affiliate stigma experience increased stress and emotional distress. Our findings highlight the importance to examine culturally specific factors that may contribute to the development of self-stigma in first-episode populations of different ethnicities.