How self-stigma affects patient activation in persons with type 2 diabetes: a cross-sectional study

Abstract

ObjectivesSelf-stigma is associated with lower patient activation levels for self-care in persons with type 2 diabetes mellitus (T2DM). However, the causal pathway linking self-stigma with patient activation for self-care has not been shown. In order to determine how self-stigma affects patient activation for self-care, we tested a two-path hypothetical model both directly and as mediated by self-esteem and self-efficacy.DesignA cross-sectional study.SettingTwo university hospitals, one general hospital and one clinic in Japan.ParticipantsT2DM outpatients receiving treatment (n=209) completed a self-administered questionnaire comprising the Self-Stigma Scale, Patient Activation Measure, Rosenberg Self-Esteem Scale, General Self-Efficacy Scale, Patient Health Questionnaire, haemoglobin A1c test, age, sex and body mass index.Primary and secondary outcome measuresSelf-stigma levels were measured by using the Self-Stigma Scale. Patient activation levels were measured by the Patient Activation Measure.ResultsPath analysis showed a strong relationship between self-stigma and patient activation (χ2=27.55, p=0.120; goodness-of-fit index=0.97; adjusted goodness-of-fit index=0.94; comparative fit index=0.98; root mean square error of approximation=0.04). Self-stigma had a direct effect on patient activation (β=−0.20; p=0.002). Indirectly, self-stigma affected patient activation along two paths (β=0.31; p<0.001) by reducing self-esteem (β=−0.22; p<0.001) and self-efficacy (β=−0.36; p<0.001).ConclusionsDue to the cross-sectional design of the study, longitudinal changes between all the variables cannot be established. However, the findings indicate that self-stigma affected patient activation for self-care, both directly and as mediated by self-esteem and self-efficacy. Interventions that increase self-esteem and self-efficacy may decrease self-stigma in patients with T2DM, thus increasing patient activation for self-care.

A Cross-Sectional Analysis of the Stigma Surrounding Type 2 Diabetes in Colombia

“…The findings of this study support a negative relationship between stigma, self-esteem, and self-efficacy. In addition, these variables showed a significant mediating role in the relationship between stigma and self-management behavior, a result that is consistent with previous findings in patients with diabetes [ 23 ]. Corrigan, et al [ 58 ] noted that this may be due to a process in which patients internalize the stereotypes that exist around their condition (e.g., those that allude to individual responsibility) and then fall into a state of personal devaluation that damages their self-esteem and self-efficacy and ultimately prevents them from achieving their goals (e.g., managing their disease).…”

“…However, the mechanisms involved in this relationship still require investigation. Evidence in this area has shown that stigma can negatively affect psychosocial and behavioral aspects that are key to achieving good disease management [ 19 , 20 , 22 , 23 , 24 ].…”

“…From the psychosocial point of view, stigma has been negatively correlated with self-efficacy and self-esteem and positively correlated with stress among people who suffer from the disease [ 20 , 23 , 25 , 26 ]. Additionally, relationships with health care providers can be affected by perceived stigma, which may lead patients to avoid medical consultations [ 20 , 27 ].…”

“…Additionally, relationships with health care providers can be affected by perceived stigma, which may lead patients to avoid medical consultations [ 20 , 27 ]. Diabetes stigma has also been linked to less engagement in diabetes self-management behaviors (e.g., adherence to pharmacological treatments and lifestyle changes) [ 19 , 23 , 26 , 28 ].Some psychosocial variables, such as those mentioned above, may have a mediation role in the relationship between stigma and self-management behaviors [ 12 , 20 , 23 , 26 , 29 ].…”

Quality of life in patients with comorbid serious mental illness and chronic diseases: A structural equation model

“…Notably, in the present study, the effects of internalized stigma on quality of life were mediated by activation behaviours in the final model, which further proved the importance of patient activation. In a related study, internalized stigma in Japanese patients with type 2 diabetes was found to be strong contributor to patient activation for self‐care (Kato et al., 2020). Our study further revealed that psychiatric symptoms directly influenced the severity of comorbidities, which in turn directly influenced internalized stigma; internalized stigma then in turn directly influenced patient activation, which ultimately influenced quality of life.…”