Abstract
Type 2 diabetes mellitus (T2DM) is a chronic, lifelong disease that can negatively affect patients’ mental health and quality of life (QoL). A notable proportion of patients with T2DM worldwide have experienced stigma through instances of discrimination, unfair social treatment and lack of promotion opportunities. Stigma refers to the negative emotional experience of people with illness, often mixed with self-stigmatization. Stigma remains an obstacle to patients’ self-management, its association with patients with T2DM on medication adherence and QoL in China are unknown. Therefore, the objective of the study was to analyze the status of stigma in patients with T2DM and its association with medication adherence and QoL in China. A cross-sectional, observational study among 346 inpatients with T2DM in 2 tertiary-level hospitals in Chengdu, China, was conducted using a general data questionnaire, Chinese version type 2 diabetes stigma scale (DSAS-2), Morisky medication adherence scale (MMAS-8) and diabetic QoL specificity scale by convenient sampling method from January to August 2020. The total score and scores for the 3 dimensions of stigma, treated differently, blame and judgment, and self-stigma, were 54.30 ± 12.22, 16.57 ± 4.06, 20.92 ± 4.42, 16.82 ± 4.78, respectively. The scores for medication adherence and QoL were 5.43 ± 1.8 and 73.24 ± 9.38. Pearson correlation analysis showed that the total score of stigma and the scores of each dimension were negatively weak-correlated with the score of medication adherence (r = −0.158 to −0.121, P < .05), and positively moderate-correlated with the score of QoL (R = 0.073 to 0.614, P < .05). Stigma of patients with T2DM was negatively associated with medication adherence, and negatively associated with QoL, namely, the stronger the stigma, the worse the medication adherence and QoL. The results of the hierarchical regression analysis revealed that stigma independently explained 8.8% of the variation in medication adherence and 9.4% to 38.8% of the variation in QoL. The stigma of patients with T2DM was at a moderate degree and negatively correlated with medication adherence and QoL, it is necessary to pay more attention to relieve stigma and negative emotions timely, in order to improve patients’ mental health and QoL.
Keywords: effect, medication adherence, quality of life, stigma, type 2 diabetes mellitus (T2DM)
1. Introduction
According to International Diabetes Federation,[1] China had the highest number of adults with diabetes mellitus in the world in 2021, with up to 140.9 million. A survey showed that the prevalence of diabetes mellitus (DM) among people aged 18 and above in China was 11.2%, while type 2 diabetes mellitus (T2DM) accounts for more than 90% of the population.[2] Unhealthy lifestyle is an important factor that increases the risk of DM, so patients require lifelong medication to control blood glucose that the financial burden is heavy. Patients with diabetes are prone to various complications, including diabetic retinopathy, diabetic foot and other functional disorders. Such dysfunction can endanger vital organs such as heart, brain, and kidneys, resulting in reduced self-care and quality of life (QoL).[2,3] Therefore, many patients with DM develop psychological problems, such as depression, anxiety.[3] Psychological burden that contributes to the imbalance of physical and mental health in patients with DM, which leads to the stigma.[3,4]
Stigma is a process that includes 5 factors: marking, stereotype, isolation, emotional response, loss of status and discrimination. Stigma can be divided into 3 categories: actual stigma, perceived stigma, and internalized stigma based on the source.[4] In recent years, Australia, Singapore, and the United States have reported stigma associated with DM.[5–7] Some studies revealed that stigma of DM is an obstacle to patient self-management.[8,9] Nicolucci et al[9] showed that one fifth of patients with DM in many countries have experienced discrimination, and the proportion in China as high as 19.1%, compared to 10.6% in USA. Patients with DM suffer from unfair treatment such as dismissal and lack of promotion opportunities and salary increase. Taken together, these studies prominently represented that stigma has a negative effect on DM.
Poor medication adherence and QoL are common among patients with T2DM worldwide. A study[10] showed that medication adherence was directly proportional to clinical treatment effect; that is, the better the medication adherence, the more satisfactory the clinical treatment effect. Medication is one of the classic treatment options for diabetes and requires a high level of medication adherence. With aging, prolonged disease duration, various medications and other complications, patient medication adherence typically decreases.[11] Balkhi et al[12] found that most patients with T2DM in Saudi Arabia had poor medication adherence, some had excessive medication, while some have medication oversupply. Gonzalez Heredia et al[13] indicated that patients with T2DM who suffered from anxious depression tend to have reduced medication adherence. QoL is an objective indicator for evaluating patient rehabilitation effects and disease regression.[14] The American Diabetes Association guidelines holds that improving the quality of patient health-related survival is one of the goals of optimal DM management.[15] Several studies have shown that patients with DM have a lower QoL than the general population[16–18] and that poor psychological and physiological status reduce their QoL. Bradley et al[17] revealed that the impact of DM on the QoL of patients in 9 European countries was negative, with close to 3/4 of patients thought that their QoL would been better without DM. In addition, Jeong[18] found that the duration of DM was related to low QoL in 1228 cases with DM in South Korea; with the course of DM prolonged and complications developed, patients had more severe problems with mobility, self-care, and daily activities that affected overall QoL.
Stigma could have a negative effect on medication adherence, mental health, and QoL of patients with DM, meanwhile suggesting stigma and QoL may have a bidirectional relationship.[19] Gonzalez et al[20] found stigma in patients with T2DM affected medication adherence, which was positively correlated with self-management behaviors and negatively correlated with HbA1c levels in adult patients, especially in patients with co-morbid depression. In addition, some studies[21,22] showed that stigma could play a key role in negative attitudes, known as “psychological insulin resistance” in patients with DM. Psychological insulin resistance refers to the psychological opposition towards insulin initiation or use in patients with DM and their prescribers, which is considered the main barrier to effective insulin therapy. The impact of stigma on patients is not only related to injustice and inequality, such as dismissal, lack of opportunities for promotion and salary increases,[3] but also affects QoL.[23] Gredig et al[23] showed that stigma in patients with DM in Switzerland positively correlated with psychological stress and depressive symptoms, which indicated a possible decrease in the QoL. In addition, studies have confirmed that the stigma of DM impairs patients’ self-care behavior and reduces patients’ motivation to self-care.[24]
Currently studies of stigma in China mainly focused on AIDS, mental illness and cancer, etc, and no study on the effect of diabetes stigma on medication adherence and QoL. Therefore, the objective of our study was to investigate the current situation of stigma in patients with T2DM in China, the influence of stigma with medication adherence and QoL in China, and provide a basis for clinical research to formulate intervention measures to improve medication adherence and QoL in patients with T2DM in China.
2. Methods
2.1. Participants and procedures
Positive psychology theory stated that by guiding individuals to develop positive emotional cognitive behaviors and self-emotional management skills, and to tap into and stimulate their own positive energy, it could induce patients’ negative emotional perceptions to turn into positive energy. Based on the above theory, we conducted a questionnaire survey among inpatients with T2DM from 2 tertiary-level hospitals in Chengdu, Sichuan Province, China, from January to August 2020. Based on the principle that the sample size is 5 to 10 times the number of questionnaire questions for the main study variable,[25] the main scale (DSAS-2) item of this study was 19, so the study required a minimum sample of 190, and a total of 360 questionnaires were finally distributed.
The inclusion criteria were as follows: inpatients who met the Chinese guidelines for the prevention and treatment of T2DM (2017 version)[26]; time of diagnosis ≥ 6 months; age 18 to 80 years old; inpatients currently using oral hypoglycemic drugs or insulin therapy; capable of filling in the questionnaire independently or completing the questionnaire with the help of investigators; and providing informed consent to participate in this study voluntarily. Inpatients who had serious cognitive impairment, mental illness, inability to communicate normally, with critical condition were excluded.
2.2. Measures
Combined with the reviewed literature and main contents of this study, the researchers designed a general data questionnaire, including demographic sociological data, such as gender, age, education, marital status, occupation, family per capita monthly income, medical payment methods, living conditions, and general disease data, such as disease course, family history, number of hospitalizations, complications, and glucose-lowering treatment options.
2.2.1. Stigma.
The Chinese version Type 2 Diabetes Stigma Assessment Scale (DSAS-2)[27] was adopted, compiled by Browne et al.[28] The 19-item self-rating scale includes 3 dimensions: treated differently, blame and judgment, and self-stigma. The Likert 5-point scale was used for assessment and the total score was 95. The higher the score, the stronger the stigma felt or experienced by patients with T2DM. The reliability and validity of the Chinese version DSAS-2 scale were good, and the Cronbach α coefficient of the scale was 0.879, the retest reliability was 0.835, and the content validity index was 0.916; thus, it is suitable for the study of stigma in patients with T2DM in China.
2.2.2. Medication adherence.
We adopted the Morisky Medication Adherence Scale (MMAS-8),[29] which reflected patients’ medication adherence in the past 2 weeks. Its effectiveness and practicability have been verified in patients with hypertension, with high internal consistency.[30,31] The scale has 8 questions, of which 1 to 7 are binomial choices (1–7 are scored as yes = 0, no = 1, and the score of 5 is reversed), and 5 choices of question 8 are (never = 1, occasionally = 0.75, sometimes = 0.5, often = 0.25, always = 0). The total score is 8 points, with <6 points, 6 to 7 points and 8 points indicating low, medium, and high compliance, respectively. The Chinese MMAS-8 scale has good reliability and validity, and the Cronbach alpha coefficient of the Chinese MMAS-8 scale was 0.81, the retest reliability was 0.95, and the face validity was 1.0. The MMAS-8 scale, content, name, and trademarks are protected by US copyright and trademark laws. A license agreement is available from MMAR, LLC., Donald E. Morisky, ScD, ScM, MSPH, 294 Lindura Ct., USA; dmorisky@gmail.com.
2.2.3. Quality of life.
The Diabetes-Specific Quality-of-Life Scale[32] was adopted, which was developed by Zhou. It includes physical, psychological or mental, social relations and treatment the 4 dimensions. Using the Likert 5 scale for scoring, the scale has 27 items and the total score is 135; the lower the score, the higher the QoL and the less affected by the disease. The diabetic QoL specificity scale has good reliability and validity, which the scale Cronbach alpha coefficient was 0.945, and the split-half reliability was 0.91.
2.3. Data collection process.
This cross-sectional study used a convenient sampling method to conduct a questionnaire survey on patients with T2DM who were evaluated based on their medical history, general information, and met the inclusion and exclusion criteria. Before the investigation, the members of the investigation team were trained uniformly, adopted the unified standard instruction, obtained the patient consent, signed the informed consent form, followed the principle of confidentiality, and filled it out anonymously. The questionnaire was filled out by the patients themselves, and the investigators explained the options to fill in. Patients with mobility difficulties and diabetic retinopathy were assisted by the investigators in answering the questions. To ensure the validity of the questionnaire, the investigators consistently checked the questionnaire for missing items, illegible handwriting, and other problems; supplemented and corrected the questionnaire in time; and collected the questionnaire on the spot. Our study was approved by the Ethics Committee of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine (NO. 2021KL-020).
2.4. Statistical analyses
Data were statistically analyzed using SPSS 23.0. The measurement data were expressed as mean and standard deviation, and the counting data were described by frequency and constituent ratio. Pearson correlation analysis was used to explore the correlation between stigma and related indices in patients with T2DM. Univariate analysis of general data was performed using the t test or analysis of variance. Hierarchical regression analysis was used to explore the effect of stigma on medication adherence and QoL, which aimed to reduce the interference of confounding factors and improve the accuracy of the results. The statistical index variables with differences in univariate analysis were set as the first-tier control variables, and the stigma score was added to the second-tier control variables. Statistical significance was set at P < .05.
3. Results
3.1. Basic characteristics of the patients with T2DM
In this study, a total of 360 questionnaires were sent out, and 346 valid questionnaires were returned, with an effective recovery rate of 96.1%. The study participants were 220 men and 126 women. The age of the subjects was 27 to 80 (57.75 ± 10.96) years, body mass index was 17.05 to 40.28 (24.34 ± 3.42) kg/m2, and the course of disease was 1 to 31 (10.08 ± 6.72) years. Population sociology and disease data are presented in Table 1.
Table 1.
General data sheet of patients with type 2 diabetes mellitus.
| Items | Classification | Numbers | Constituent ratio (%) |
|---|---|---|---|
| Age | <60 | 197 | 56.9 |
| ≥60 | 149 | 43.1 | |
| Gender | Male | 220 | 63.6 |
| Female | 126 | 36.4 | |
| BMI index | <18.5 | 6 | 1.7 |
| 18.5~23.9 | 163 | 47.1 | |
| 24~27.9 | 138 | 39.9 | |
| ≥28 | 39 | 11.3 | |
| Education | Primary school and below | 94 | 27.1 |
| Junior high school | 84 | 24.3 | |
| Senior high school or technical secondary school | 61 | 17.6 | |
| Junior college | 49 | 14.2 | |
| Undergraduate and above | 58 | 16.8 | |
| Living condition | A. Residence | ||
| Town | 298 | 86.1 | |
| Rural areas | 48 | 13.9 | |
| B. Living condition | |||
| Live alone | 31 | 8.9 | |
| Live with a spouse | 195 | 56.4 | |
| Live with children | 59 | 17.1 | |
| Others | 61 | 17.6 | |
| Occupational status | On the job | 222 | 64.2 |
| Retirement | 108 | 31.2 | |
| Be unemployed | 16 | 4.6 | |
| Marital status | Unmarried | 10 | 2.9 |
| Married | 299 | 86.4 | |
| Divorced | 11 | 3.2 | |
| Widowed | 26 | 7.5 | |
| Family per capita monthly income | <1000 | 34 | 9.8 |
| 1000~2999 | 124 | 35.8 | |
| 3000~4999 | 94 | 27.2 | |
| ≥5000 | 94 | 27.2 | |
| Medical payment methods | Urban workers’ medical insurance | 233 | 67.3 |
| Urban residents’ medical insurance | 40 | 11.6 | |
| New type of rural cooperative medical insurance | 61 | 17.6 | |
| At their own expense | 4 | 1.2 | |
| Others | 8 | 2.3 | |
| Disease course | 0.5~2 | 50 | 14.5 |
| 3~5 | 55 | 15.9 | |
| 6~10 | 103 | 29.8 | |
| 11~15 | 72 | 20.8 | |
| ≥16 | 66 | 19.0 | |
| Family history | Yes | 149 | 43.1 |
| No | 197 | 56.9 | |
| Number of hospitalizations | ≤2 | 176 | 50.9 |
| 3~5 | 104 | 30.0 | |
| 6~10 | 37 | 10.7 | |
| ≥11 | 29 | 8.4 | |
| Complications | 0 | 61 | 17.6 |
| 1~2 | 159 | 45.9 | |
| 3~4 | 95 | 27.5 | |
| ≥5 | 31 | 9.0 | |
| Glucose-lowering treatment options | Oral hypoglycemic drug | 132 | 38.2 |
| Injection insulin | 69 | 19.9 | |
| Oral hypoglycemic drug and injection insulin | 145 | 41.9 |
BMI = body mass index.
3.2. Current status of stigma in patients with T2DM
All patients with T2DM had varying degrees of stigma. The scores of DSAS-2 and 3 dimensions of stigma (treated differently, blame and judgment, and self-stigma) were 54.30 ± 12.22, 16.57 ± 4.06, 20.92 ± 4.42, and 16.82 ± 4.78, respectively. The scores of the dimension blame and judgment were higher than those of other dimensions, and the top 3 items were item 16 (I was told, I have type 2 diabetes for my own reasons), item 11 (because I have type 2 diabetes, I don’t think I am a healthy person), and item 19 (because I have type 2 diabetes, some people would judge the food I chose). It predicted that patients with T2DM tended to integrate external negative evaluation and adverse disease experience, resulting in blame judgment and self-discrimination.
3.3. Correlation among stigma, medication adherence, and QoL in patients with T2DM
The scores of medication adherence and QoL of patients with T2DM were 5.43 ± 1.89, 61.24 ± 9.38, respectively. The total score and each dimension score of the DSAS-2 scale were negatively weakly-correlated with the score of medication adherence, and positively moderately-correlated with the score of QoL, suggesting that the stronger the stigma, the worse the medication adherence and QoL (Table 2).[33] Considering that orals only regimens were vastly different from others [insulin only or mixed (orals and insulin)] regimens, we correlated these 2 subgroups with the total score and each dimension of DSAS-2 as well, and the results showed that the total scores of stigma and all dimensions were negatively correlated with orals only (r = −0.231 to −0.086, P < .05) and others (r = −0.177 to −0.107, P < .05).
Table 2.
Analysis of the correlation between stigma, medication adherence and quality of life in patients with type 2 diabetes mellitus.
| Scales | DSAS-2 score | Discrimination | Blame and judgment | Self-stigma | ||||
|---|---|---|---|---|---|---|---|---|
| r | P | r | P | r | P | r | P | |
| MMAS-8 score | −0.151 | .011 | −0.140 | .019 | −0.158 | .008 | −0.121 | .042 |
| DSQL score | 0.438 | <.001 | 0.437 | <.001 | 0.321 | <.001 | 0.452 | <.001 |
DSAS-2 = Type 2 Diabetes Stigma Assessment Scale, DSQL = Diabetes Quality of Life Specificity Scale, MMAS-8 = Morisky Medication Adherence Scale.
3.4. Analysis of factors influencing stigma, medication adherence and QoL in patients with T2DM
Univariate analysis of the influence factors of demographic sociology and disease data on related indexes of patients with T2DM, performed using the bivariate t test or multivariate analysis of variance, indicated that there were main effects on medication adherence with education (F = 5.381, P < .001), residence (t = 13.023, P < .001), marital status (F = 4.932, P = .002), family per capita monthly income (F = 3.409, P = .018), number of hospitalizations (F = 6.539, P < .001), complications (F = 14.529, P = .002), and glucose-lowering treatment options (F = 9.144, P < .001). Main effects on the QoL were observed with age (t = −3.714, P < .001), gender (t = −2.753, P = .06), living condition (F = 2.711, P = .045), family monthly income per capita (F = 13.951, P < .001), course of disease (F = 4.156, P = .003), family history (t = 2.466, P = .014), number of hospitalizations (F = 8.470, P < .001), complications (F = 19.573, P < .001), and glucose-lowering treatment options (F = 4.733, P = .010).
Using hierarchical regression analysis to explore the influencing factors of stigma on related indexes in patients with T2DM, medication adherence and QoL were taken as dependent variables, and significant demographic sociology, disease data variables, and stigma scores in univariate analysis were taken as independent variables. The first layer included demographic sociology and disease data, and the second layer included stigma scores. For the independent variable assignment, dummy variables were used to represent 2 classification variables and disordered classification variables, as shown in Table 3. The results indicated that after controlling for demographic sociology and disease data, the stigma had a significant independent contribution to the related indexes (P < .01), as shown in Table 4. The stigma independently explained 8.8% of the changes in medication adherence and 9.4% to 38.8% of the changes in QoL life in patients with T2DM.
Table 3.
Details of independent variable assignment.
| Independent variable | Dummy variable 1 | Dummy variable 2 | Dummy variable 3 | |
|---|---|---|---|---|
| Age | <60 | 0 | ||
| ≥60 | 1 | |||
| Gender | Male | 0 | ||
| Female | 1 | |||
| Education | Primary school and below | 1 | ||
| Junior high school | 2 | |||
| Senior high school or technical secondary school | 3 | |||
| Junior college | 4 | |||
| Undergraduate and above | 5 | |||
| Residence | Town | 0 | ||
| Rural | 1 | |||
| Living condition | Living alone | 0 | 0 | 0 |
| Live with spouse | 1 | 0 | 0 | |
| Live with children | 0 | 1 | 0 | |
| Other | 0 | 0 | 1 | |
| Marital status | Unmarried | 0 | 0 | 0 |
| Married | 1 | 0 | 0 | |
| Divorced | 0 | 1 | 0 | |
| Widowed | 0 | 0 | 1 | |
| Family per capita monthly income | <1000 | 1 | ||
| 1000~2999 | 2 | |||
| 3000~4999 | 3 | |||
| ≥5000 | 4 | |||
| Course of disease | 0.5~2 | 1 | ||
| 3~5 | 2 | |||
| 6~10 | 3 | |||
| 11~15 | 4 | |||
| ≥16 | 5 | |||
| Family history | Yes | 0 | ||
| No | 1 | |||
| Number of hospitalizations | ≤2 | 1 | ||
| 3~5 | 2 | |||
| 6~10 | 3 | |||
| ≥11 | 4 | |||
| Complications | 0 | 1 | ||
| 1~2 | 2 | |||
| 3~4 | 3 | |||
| ≥5 | 4 | |||
| Glucose-lowering treatment options | Oral hypoglycemic drugs | 0 | 0 | |
| Insulin injection | 1 | 0 | ||
| Oral hypoglycemic drugs + injected insulin | 0 | 1 |
Table 4.
Hierarchical regression analysis of the effect of stigma on related indexes in patients with type 2 diabetes mellitus.
| Related index | Layer | Variable | F | R2 | ΔR2 |
|---|---|---|---|---|---|
| Medication adherence | 1 | Education degree, residential areas, marital status, family monthly income per capita, number of hospitalizations, complications, glucose-lowering treatment options | 3.861* | 0.124 | 0.092 |
| 2 | Education degree, residential areas, marital status, family monthly income per capita, number of hospitalizations, complications, glucose-lowering treatment options, stigma | 3.576* | 0.127 | 0.091 | |
| Quality of life | |||||
| Physical | 1 | Education degree, residential areas, marital status, family monthly income per capita, number of hospitalizations, complications, glucose-lowering treatment options | 6.458* | 0.208 | 0.176 |
| 2 | Education degree, residential areas, marital status, family monthly income per capita, number of hospitalizations, complications, glucose-lowering treatment options, stigma | 5.910* | 0.208 | 0.173 | |
| Psychological/mental | 1 | Education degree, residential areas, marital status, family monthly income per capita, number of hospitalizations, complications, glucose-lowering treatment options | 2.713* | 0.099 | 0.063 |
| 2 | Education degree, residential areas, marital status, family monthly income per capita, number of hospitalizations, complications, glucose-lowering treatment options, stigma | 5.185* | 0.187 | 0.151 | |
| Social relations | 1 | Education degree, residential areas, marital status, family monthly income per capita, number of hospitalizations, complications, glucose-lowering treatment options | 5.052* | 0.170 | 0.136 |
| 2 | Education degree, residential areas, marital status, family monthly income per capita, number of hospitalizations, complications, glucose-lowering treatment options, stigma | 16.627* | 0.425 | 0.399 | |
| Treatment | 1 | Education degree, residential areas, marital status, family monthly income per capita, number of hospitalizations, complications, glucose-lowering treatment options | 1.828* | 0.069 | 0.031 |
| 2 | Education degree, residential areas, marital status, family monthly income per capita, number of hospitalizations, complications, glucose-lowering treatment options, stigma | 3.149* | 0.123 | 0.084 |
P < .01.
4. Discussion
In this study, the stigma of patients with T2DM in China was at a moderate degree, which was similar to the results of Wei et al[34] and higher than that of Browne et al,[28] which may be related to the differences in cultural background and medical payment security system. Influenced by the traditional Confucian culture, Chinese tend to be more subtle and introverted in their expression of emotions. Some self-pay patients cannot apply for special outpatient medical treatment for DM, and their stigma is much higher as our study showed. T2DM is a long and complicated disease, coupled with long-term regular blood glucose monitoring, lifelong medication (especially insulin use), and heavy economic burden causes it to be of concern. Due to the physiological damage caused by complications, it could affect normal social activities, resulting in physical and mental health imbalance. Taken together, these factors account for the source of stigma in most patients.[3,35] Moreover, Chinese residents have long been deeply influenced by traditional culture, and personal expression of emotions tend to be subtle and subdued.[36] The occurrence or aggravation of complications such as blindness due to retinopathy and amputation of diabetic foot in patients with T2DM make them less able to work and take care of their families, so they were prone to emotions such as self-denial and aggravate the stigma.[37,38] Furthermore, the patients´ self-care ability was reduced by T2DM, the disease pain was more severe, blood glucose control and management was more difficult, and the internal was prone to negative emotions such as self-worth depreciation, which seriously affected the patients´ QoL and increased stigma.[36,37] In this study, blame and judgment dimension as important sources influencing patients’ stigma, which was consistent with the results of Zhang et al.[39] Among the top 3 items of stigma score (items 16, 11, and 19), items 16 and 19 belong to the blame and judgment dimension, while item 11 belongs to the self-stigma dimension. The results indicated that patients with T2DM tended to integrate negative evaluations and adverse disease experiences, leading to self-blame judgments and self-discrimination.
Notably, there are great misunderstandings and general stereotypes in the public awareness and perception of T2DM, which is an important source of stigma. Patients with T2DM were often associated with drug addicts, overweight, poor self-control ability. Further, negative coverage by the news media was 1 major factor in the formation of DM stereotypes by the public.[40] In addition, some medical workers[37,40,41] would blame patients with DM for poor glycemic control and recurrent morbidity, attributing them to improper diet, lack of exercise, and irregular blood glucose monitoring, thus patients perceived their discrimination and increased their stigma. Over-care of the patients from their relatives and friends with good intentions, especially in the management of diet and exercise, is also a source of stigma for patients with T2DM.[40] It was suggested that medical staff should strengthen the evaluation of stigma in patients with T2DM, carry out targeted prevention and intervention, conduct and offer self-group management support[42] and community education,[43] enhance communication with patients with T2DM and their families, establish correct disease perceptions, and family members moderately empower patients to increase their self-confidence and reduce their stigma. Meanwhile the public (society, media, relatives, etc) should change cognitive misunderstandings and create a positive social environment to reduce stigma of patients with T2DM and improve their medication adherence and QoL.
The results of this study showed that the stronger the patients´ stigma, the poorer their medication adherence, which was consistent with Luo et al,[36] although the correlations between stigma and adherence were small but significant. Drug therapy is currently the main treatment for T2DM, and patients need to take drugs perpetually to control blood glucose and delay the development of complications. Patients’ stigma could lead to low self-esteem, shame and other psychological concerns about drug side effects and dependence, which could aggravate disease hidden behavior and further affect their medication adherence.[20] Jeragh-Alhaddad et al[44] indicated that stigma hindered medication adherence in patients with T2DM; patients would not take medicine in front of others because they were worried about the stigma with the disease, which strengthened the belittling and discriminating attitude of the public. thus forms a vicious cycle. Therefore, health education related to disease etiology and treatment should be provided to patients, medical personnel and the public to improve public awareness of T2DM, reduce patients’ low self-esteem and enhance self-confidence so that they can voluntarily expose the disease voluntarily. Further, interventions such as experience sharing and proper education are used to enhance awareness of T2DM and positively influence patients to strengthen their social interactions and seek help from others.
Our study suggested that stigma negatively affected the QoL of patients with T2DM in China simultaneously, and the higher patients´ stigma, the worse the QoL, which was consistent with Gredig et al.[23] Factors affecting the QoL included disease, social support and psychological status.[45] As the disease progresses and complications occur, the physiological impairment brings about a significant decline in the patient physical strength and self-care ability, especially in elderly patients, whose social ability were significantly limited.[46] In addition, the heavy financial burden of long-term treatment brings challenges to the financial and care needs. Misunderstandings and prejudices from the people in their circle and the public would reduce patients’ social enthusiasm, initiative, and social function.[8] Moreover, patients with T2DM generally have negative emotions, such as anxiety and depression,[47] which can easily lead to a negative mindset. Stigma may increase the release of inflammatory factors and damage the function of the immune system by aggravating the negative mentality, leading to worsening of the disease or frequent relapses.[47, 48] These factors led to a decline in the patients’ QoL. Therefore, health education of patients with T2DM and their families should be strengthened to urge them to comply with treatment, while paying attention to their psychological problems. Through combining positive psychology and mindfulness with routine clinical care, psychological counseling, and humanistic care these psychological intervention measures are enhanced to reduce patients’ stigma, anxiety, and depression,[49] thus improving the patients’ QoL.
4.1. Limitations
This study had several limitations. First, this was a cross-sectional survey, which only reflected the stigma status of cases at one point in time and cannot accurately explain the dynamic process of stigma during the course of T2DM. We could also not accurately infer a causal relationship between stigma and medication adherence and QoL variables. Longitudinal studies could be used to monitor the dynamics of stigma in patients with T2DM over time. Second, this study used a convenience sampling method to investigate inpatients with T2DM from the endocrinology departments of only 2 hospitals. The sample size was small, and the indicators used were subjective and not representative enough. Thus, the sample size of the study should be expanded to increase the representativeness of the study results. Third, the participants were Chinese inpatients with T2DM. Thus, this result may not be generalizable to patients with T2DM in other countries because of the strong influence of traditional Confucian culture,[34] as revealed in a Swiss survey[23] on stigma. Fourth, we recruited inpatients from tertiary-level hospitals, excluding discharged patients, patients treated in community hospitals, patients not participating in treatment, and patients with severe illness; besides the medication adherence may be overestimated and the stigma level may be underestimated. Multicenter and large-scale studies in future research will be needed to clarify the generalizability of our findings.
5. Conclusions
The stigma of patients with T2DM in China was at a moderate degree. After controlling for demographic sociology and disease data, the stigma could negatively related with patients’ medication adherence and QoL, suggesting that it deserves attention of more professionals and it is essential to relieve stigma and negative emotions timely, in order to improve patients’ mental health and QoL.
Acknowledgments
We are grateful to the volunteers and patient advisers of their valued involvement, and those individuals who offered further feedback in the process of resource investigation.
Author contributions
Conceptualization: Jie Yun.
Data curation: Xiaoyan Li, Lingyun Wu.
Formal analysis: Xiaoyan Li, Qiuhua Sun.
Investigation: Xiaoyan Li.
Methodology: Xiaoyan Li, Lingyun Wu.
Project administration: Qiuhua Sun.
Software: Xiaoyan Li.
Supervision: Jie Yun, Qiuhua Sun.
Writing – original draft: Xiaoyan Li, Lingyun Wu.
Writing – review & editing: Jie Yun, Qiuhua Sun.
Abbreviations:
- DM
- diabetes mellitus
- DSAS-2
- type 2 diabetes stigma assessment scale
- MMAS-8
- Morisky medication adherence scale
- QoL
- quality of life
- T2DM
- type 2 diabetes mellitus
XL and LW contributed equally to this work.
All data generated or analyzed during this study are included in this published article [and its supplementary information files].
Our study was approved by the Ethics Committee of the Affiliated hospital of Chengdu University of Traditional Chinese Medicine and received support from the participating institutions (NO. 2021KL-020).
The authors have no funding and conflicts of interest to disclose.
How to cite this article: Li X, Wu L, Yun J, Sun Q. The status of stigma in patients with type 2 diabetes mellitus and its association with medication adherence and quality of life in China: A cross-sectional study. Medicine 2023;102:26(e34242).
Contributor Information
Xiaoyan Li, Email: qq1026728769@163.com.
Lingyun Wu, Email: 173219091@qq.com.
Jie Yun, Email: chengduwest@163.com.
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