Abstract
Background:
Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), carries substantial physical and psychosocial burdens. Illness-related stigma may adversely affect quality of life (QoL), while perceived social support may be associated with these relationships. However, evidence from Saudi Arabia remains limited. This study examined the associations among stigma management strategies, perceived social support, and QoL among adults with IBD in Saudi Arabia.
Methods:
A cross-sectional study was conducted among 103 adults with a self-reported gastroenterologist diagnosis of CD or UC. Participants were recruited using convenience and snowball sampling through online patient support groups, healthcare networks, and WhatsApp groups. Data were collected using an adapted Stigma Management Strategies Scale, the Multidimensional Scale of Perceived Social Support, and the WHOQOL-BREF. Group comparisons and bootstrap analyses of indirect associations were performed.
Results:
Education/advocacy was the most frequently reported stigma management strategy, whereas withdrawal was the least common. Family was the highest perceived source of social support. Bootstrap analyses identified significant indirect associations involving perceived social support between secrecy, withdrawal, and poorer QoL, whereas education/advocacy showed positive indirect associations with QoL. Preventive telling showed no significant indirect associations. Participants with UC reported significantly higher social relationships and overall QoL scores than those with CD.
Conclusion:
Adaptive stigma management strategies and greater perceived social support were associated with better QoL among adults with IBD in Saudi Arabia, whereas concealment-based strategies were associated with poorer QoL. Longitudinal studies incorporating disease activity and other clinical factors are needed to confirm these findings.
Keywords: Crohn's disease, inflammatory bowel disease, quality of life, Saudi Arabia, social support, stigma, ulcerative colitis
INTRODUCTION
Inflammatory bowel disease (IBD), primarily comprising Crohn's disease (CD) and ulcerative colitis (UC), is a group of chronic, idiopathic disorders characterized by relapsing and remitting inflammation of the gastrointestinal tract.[1] Globally, IBD affects more than 5 million people, and its prevalence continues to increase, particularly in newly industrialized regions.[2] Similar trends have been observed in Saudi Arabia and other Gulf Cooperation Council (GCC) countries, where rapid urbanization and lifestyle changes have contributed to a growing disease burden.[3] Despite advances in medical treatment, IBD remains a lifelong condition that often begins during early adulthood and substantially affects patients’ physical, psychological, and social well-being.[4]
Beyond gastrointestinal symptoms, individuals with IBD frequently experience illness-related stigma, an often-overlooked psychosocial challenge that may adversely affect quality of life (QoL). Stigma refers to a socially devalued characteristic that limits an individual’s acceptance within society.[5] Since IBD involves symptoms related to bowel function, which are frequently perceived as embarrassing or socially taboo, patients commonly report feelings of shame, fear of judgment, and social isolation.[6,7] In Saudi Arabia, where cultural norms and societal expectations strongly influence perceptions of chronic illness, concerns about stigma may further discourage individuals from openly discussing their condition or seeking psychosocial support.[8,9]
To navigate these social challenges, individuals with concealable stigmatized identities (CSI), such as IBD, use various stigma management strategies. These strategies generally include secrecy, which involves hiding the illness status to “pass” as healthy; withdrawal, which involves avoiding social interactions to prevent identity detection; and preventive telling, which involves proactively disclosing the condition to educate others and gain understanding.[10,11,12,13] Previous studies suggest that adaptive strategies, such as education and open communication, are associated with better psychosocial outcomes, whereas concealment-based strategies, including secrecy and withdrawal, have been linked to greater psychological distress and poorer QoL.[14,15,16]
Perceived social support is another important psychosocial factor associated with health outcomes among individuals with CD. Support from family, friends, and significant others may enhance coping, reduce emotional distress, and contribute to better QoL.[17,18] Previous research has also suggested that different stigma management strategies are associated with varying levels of perceived social support, which may in turn be associated with patients’ psychosocial well-being and QoL.[14,18] Given the strong family-centered culture in Saudi Arabia, understanding the role of perceived social support in patients living with IBD is particularly relevant.
Although previous studies have demonstrated associations between stigma, social support, and QoL among individuals with IBD, evidence from Saudi Arabia remains scarce. Moreover, little is known about how different stigma management strategies relate to perceived social support and QoL among adults with IBD in Saudi Arabia. Addressing this knowledge gap may help inform the development of culturally appropriate psychosocial interventions and support more patient-centered IBD care.
Therefore, this study aimed to examine the associations among stigma management strategies, perceived social support, and QoL among adults with IBD in Saudi Arabia. In addition, the study explored whether perceived social support was indirectly associated with the relationship between stigma management strategies and QoL, using exploratory bootstrap analyses.
MATERIALS AND METHODS
Study design and participants
A cross-sectional observational study was conducted to examine the associations among stigma management strategies, perceived social support, and QoL among adults with IBD in Saudi Arabia. The study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.[19]
The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Standing Committee for Scientific Research Ethics at Taibah University, Madinah, Saudi Arabia (Reference No: TU-PHR-25-12-001). Participation was voluntary, and all participants provided informed consent before data collection. Confidentiality and anonymity were strictly maintained throughout the study period.
Participants were eligible if they were aged ≥18 years, resided in Saudi Arabia, and reported having previously received a diagnosis of CD or UC from a gastroenterologist. The diagnosis was based solely on the participants' self-reporting and was not independently verified through medical records or physician confirmation.
Participants were recruited between July and December 2025 using convenience and snowball sampling through online patient support groups, healthcare networks, and WhatsApp groups. Approximately 390 individuals were invited to participate, of whom 201 responded (initial response rate: 51.5%). After eligibility screening, exclusion of individuals with other gastrointestinal conditions (n = 42), incomplete questionnaires (n = 30), and those who declined participation (n = 26), 103 participants were included in the final analysis (final analytic sample rate: 26.4% of invited participants).
Since no previous Saudi study examining these psychosocial relationships in IBD was available to inform an a priori sample size calculation, recruitment continued throughout the study period to maximize participation. Nevertheless, the relatively modest sample size should be considered when interpreting subgroup and indirect association analyses.
To encourage participation, participants were entered into a random prize draw, with four individuals each receiving a SAR 150 electronic gift card (total value: SAR 600). The incentive was offered irrespective of participants’ responses and was not contingent upon questionnaire completion or study findings.
Data collection procedure
Data were collected using a secure, self-administered online questionnaire. Before accessing the questionnaire, participants received information describing the study objectives, voluntary nature of participation, confidentiality procedures, and electronic informed consent process.
The questionnaire was translated into Arabic using forward translation, back-translation by two bilingual researchers, and independent review by three experts with experience in health research and psychosocial measurement. To ensure conceptual and linguistic equivalence. A pilot study was subsequently conducted to evaluate clarity and readability.
Although the adapted questionnaire demonstrated acceptable to excellent internal consistency, comprehensive psychometric validation, including exploratory factor analysis, confirmatory factor analysis, and criterion validity, was not performed in the current sample.
Measures
Demographic and clinical characteristics
Participants reported their age, gender, nationality, education level, marital status, employment status, diagnosis (CD or UC), disease duration, and recent negative emotional experiences. These variables were used to describe the study population and perform subgroup comparisons.
Stigma management strategies
Stigma management strategies were assessed using an Arabic adaptation of the Stigma Management Strategies Scale (SMSC), originally developed to assess stigma management among individuals with concealable stigmatized identities and subsequently applied in IBD populations.[5,14,20,21] The instrument was adapted for the present study to reflect the experiences of adults with CD and UC in Saudi Arabia. The adaptation process included forward-backward translation, expert review, and pilot testing to ensure linguistic and cultural appropriateness. However, comprehensive psychometric validation of the adapted version, including assessment of construct and criterion validity, was not performed in this study.
The adapted SMSC consists of 16 items that measure four stigma management strategies: secrecy, withdrawal, preventive telling, and education/advocacy, with four items per subscale. Responses were recorded on a 6-point Likert scale from 1 (strongly disagree) to 6 (strongly agree), with higher scores indicating greater use of the corresponding stigma management strategy. Internal consistency of the subscales was assessed using Cronbach alpha in the present sample.
Perceived social support
Perceived social support was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS), a widely used 12-item instrument that measures perceived support from three sources: family, friends, and significant others.[22] Each subscale consists of four items rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree), with higher scores indicating greater perceived social support. Mean scores were calculated for each subscale, and an overall MSPSS score was computed by averaging all 12 items. Internal consistency of the MSPSS and its subscales was evaluated in this study using Cronbach alpha.
Quality of life (QoL)
QoL was assessed using the World Health Organization Quality of Life–BREF (WHOQOL-BREF), a widely used 24-item instrument that measures subjective QoL over the preceding 2 weeks across four domains: physical health (7 items), psychological well-being (6 items), social relationships (3 items), and environment (8 items).[23] Items are rated on a 5-point Likert scale, with higher scores indicating better QoL. Domain scores were calculated according to the WHOQOL-BREF scoring guidelines by averaging the items within each domain and multiplying the mean score by 4 to ensure comparability with the original WHOQOL-100 instrument. Internal consistency of the WHOQOL-BREF domains was evaluated in this study using Cronbach alpha.
Statistical analysis
Data were analyzed using IBM SPSS Statistics version 31 (IBM Corp., Armonk, NY, USA). Missing data were minimal (age: n = 2; diagnosis: n = 1; <2% overall); therefore, no imputation was performed, and analyses were conducted using available cases. Internal consistency of each scale was assessed using Cronbach alpha coefficients, with values ≥0.70 considered acceptable.[24]
Continuous variables are presented as means and standard deviations (SD), whereas categorical variables are presented as frequencies and percentages. The Shapiro–Wilk test was used to assess the normality of continuous variables. Independent sample t-tests were performed to compare QoL scores according to disease type (CD vs. UC) and sex.
To examine the indirect associations involving perceived social support in the relationships between stigma management strategies and QoL, regression-based path analyses were conducted using Hayes’ PROCESS macro (version 4.2) for SPSS (Model 4). Indirect effects were estimated using 5,000 bias-corrected bootstrap resamples while controlling for age and gender. Indirect associations were considered statistically significant when the 95% bias-corrected confidence interval (CI) did not include zero.
RESULTS
Participants’ demographic and clinical characteristics
A total of 103 adults with a self-reported gastroenterologist diagnosis of IBD were included in the analysis. The majority were female (72.8%) and Saudi nationals (72.8%). The mean age was 28.9 ± 8.5 years. Most participants were single (60.2%) and held a bachelor’s degree (58.3%). CD was reported by 56.3% of participants and UC by 42.7%. Disease duration ranged from less than 1 year to more than 10 years, with 36.9% reporting a disease duration of 1–5 years. Participant characteristics are presented in Table 1.
Table 1.
Sociodemographic and clinical characteristics of the sample (n=103)
| Variable | n (%) or Mean (SD) |
|---|---|
| Age (years)—Mean (SD) | 28.9 (8.5) |
| Gender—n (%) | |
| Male | 28 (27.2%) |
| Female | 75 (72.8%) |
| Nationality—n (%) | |
| Saudi | 75 (72.8%) |
| Non-Saudi | 28 (27.2%) |
| Marital Status—n (%) | |
| Single | 62 (60.2%) |
| Married | 38 (36.9%) |
| Divorced/widowed | 3 (2.9%) |
| Education—n (%) | |
| High school or less | 33 (32.0%) |
| Diploma | 8 (7.8%) |
| Bachelor’s degree | 60 (58.3%) |
| Postgraduate | 2 (1.9%) |
| Employment—n (%) | |
| Employed | 35 (34.0%) |
| Unemployed | 37 (35.9%) |
| Student | 30 (29.1%) |
| Retired | 1 (1.0%) |
| Region—n (%) | |
| Western | 47 (45.6%) |
| Central | 31 (30.1%) |
| Eastern | 17 (16.5%) |
| Southern/Northern | 8 (7.8%) |
| Diagnosis — n (%) | |
| Crohn’s disease | 58 (56.3%) |
| Ulcerative colitis | 44 (42.7%) |
| Disease Duration — n (%) | |
| < 1 year | 15 (14.6%) |
| 1–5 years | 38 (36.9%) |
| 6–10 years | 27 (26.2%) |
| > 10 years | 23 (22.3%) |
| Negative Emotions in Past 4 Weeks — n (%) | |
| Sometimes | 46 (44.7%) |
| Often | 25 (24.3%) |
| Always | 18 (17.5%) |
| Rarely/never | 14 (13.6%) |
Scale reliability and descriptive statistics
All SMSC subscales demonstrated acceptable to good internal consistency (Cronbach α = 0.746–0.876). The MSPSS showed excellent internal consistency for all subscales (α = 0.894–0.954), whereas the WHOQOL-BREF demonstrated acceptable to excellent reliability across domains (α = 0.692–0.870).
Among stigma management strategies, education/advocacy had the highest mean score (3.41 ± 0.90), followed by secrecy (3.16 ± 1.09), preventive telling (2.81 ± 1.05), and withdrawal (2.65 ± 1.14). Family support received the highest MSPSS score (3.95 ± 1.03). Mean WHOQOL-BREF scores indicated moderate QoL across all domains. Detailed descriptive statistics are presented in Table 2.
Table 2.
Descriptive statistics, reliability, and theoretical range of study scales
| Scale/Subscale | Mean | SD | Observed Range | Theoretical Range | α |
|---|---|---|---|---|---|
| Stigma Management Strategies (SMSC) | |||||
| Secrecy (4 items) | 3.16 | 1.09 | 1.00–5.00 | 1–6 | 0.858 |
| Preventive telling (4 items) | 2.81 | 1.05 | 1.00–5.00 | 1–6 | 0.832 |
| Withdrawal (4 items) | 2.65 | 1.14 | 1.00–5.00 | 1–6 | 0.876 |
| Education/advocacy (4 items) | 3.41 | 0.90 | 1.50–5.00 | 1–6 | 0.746 |
| Social Support (MSPSS) | |||||
| Family (4 items) | 3.95 | 1.03 | 1.00–5.00 | 1–7 | 0.911 |
| Friends (4 items) | 3.29 | 1.14 | 1.00–5.00 | 1–7 | 0.894 |
| Significant other (4 items) | 3.72 | 1.20 | 1.00–5.00 | 1–7 | 0.954 |
| Total MSPSS (12 items) | 3.65 | 0.97 | 1.08–5.00 | 1–7 | 0.951 |
| Quality of Life (WHOQOL-BREF) | |||||
| Physical health (7 items) | 3.12 | 0.62 | 1.43–4.71 | 1–5 | 0.692ᵃ |
| Psychological (6 items) | 3.33 | 0.90 | 1.00–5.00 | 1–5 | 0.852 |
| Social relationships (3 items) | 3.24 | 0.92 | 1.00–5.00 | 1–5 | 0.714 |
| Environment (8 items) | 3.23 | 0.89 | 1.00–5.00 | 1–5 | 0.870 |
| QoL total (4 domains) | 3.23 | 0.69 | 1.43–4.67 | 1–5 | — |
Note. Observed scores represent the mean of constituent items. Theoretical ranges reflect the original response scales of each instrument (SMSC: 1–6; MSPSS: 1–7; WHOQOL-BREF: 1–5).). SD=standard deviation; α=Cronbach alpha. Higher scores indicate greater levels of the construct. ᵃPhysical Health α=0.692 falls below the conventional 0.70 threshold; interpret this subscale with caution
Indirect associations involving perceived social support
Bootstrap analyses using Hayes’ PROCESS macro (5,000 resamples) examined indirect associations involving perceived social support in the relationships between stigma management strategies and quality of life while controlling for age and gender [Table 3; Figure 1].
Table 3.
Bootstrap analysis of indirect associations involving social support (5,000 samples, 95% BC CI)
| Outcome (Y) | Path a (X → SS) | Path b (SS → Y) | Total Effect c (P) | Direct Effect c′ (P) | Indirect Effect (IE) | 95% CI Low | 95% CI High | Std. Indirect Effect (β) |
|---|---|---|---|---|---|---|---|---|
| Secrecy | ||||||||
| Physical health | −0.269 | +0.237 | −0.021 (P=0.740) | +0.043 (P=0.482) | −0.064 | −0.122 | −0.012 | β=−0.111 |
| Psychological | −0.269 | +0.359 | −0.087 (P=0.327) | +0.010 (P=0.910) | −0.097 | −0.186 | −0.021 | β=−0.116 |
| Social relationships | −0.269 | +0.550 | −0.249 (P=0.005) | −0.101 (P=0.180) | −0.148 | −0.276 | −0.034 | β=−0.175 |
| Environment | −0.269 | +0.455 | −0.237 (P =. 006) | −0.114 (P=0.146) | −0.123 | −0.218 | −0.029 | β=−0.150 |
| QoL total | −0.269 | +0.400 | −0.148 (P=0.027) | −0.041 (P=0.486) | −0.108 | −0.195 | −0.029 | β=−0.170 |
| Preventive Telling | ||||||||
| Physical health | +0.143 | +0.215 | +0.078 (P=0.198) | +0.047 (P=0.418) | +0.031 | −0.015 | 0.097 | β=+ 0.052 |
| Psychological | +0.143 | +0.354 | +0.063 (P=0.463) | +0.013 (P=0.875) | +0.051 | −0.023 | 0.161 | β=+ 0.059 |
| Social relationships | +0.143 | +0.579 | +0.099 (P=0.263) | +0.016 (P=0.820) | +0.083 | −0.053 | 0.204 | β=+ 0.095 |
| Environment | +0.143 | +0.500 | +0.023 (P=0.793) | −0.049 (P=0.514) | +0.072 | −0.038 | 0.200 | β=+ 0.085 |
| QoL total | +0.143 | +0.412 | +0.065 (P=0.324) | +0.007 (P=0.907) | +0.059 | −0.031 | 0.164 | β=+ 0.090 |
| Withdrawal | ||||||||
| Physical health | −0.332 | +0.206 | −0.113 (P=0.064) | −0.045 (P=0.474) | −0.068 | −0.131 | −0.015 | β=−0.126 |
| Psychological | −0.332 | +0.295 | −0.253 (P=0.003) | −0.155 (P=0.075) | −0.098 | −0.193 | −0.024 | β=−0.124 |
| Social relationships | −0.332 | +0.506 | −0.361 (P<.001) | −0.193 (P=0.011) | −0.168 | −0.292 | −0.065 | β=−0.208 |
| Environment | −0.332 | +0.455 | −0.242 (P=0.005) | −0.091 (P=0.255) | −0.151 | −0.247 | −0.066 | β =− 0.194 |
| QoL total | −0.332 | +0.366 | −0.242 (P<.001) | −0.120 (P=. 041) | −0.121 | −0.202 | −0.050 | β=−0.201 |
| Education/Advocacy | ||||||||
| Physical health | +0.319 | +0.256 | −0.032 (P=0.651) | −0.114 (P=0.100) | +0.082 | 0.018 | 0.166 | β=+ 0.118 |
| Psychological | +0.319 | +0.397 | −0.015 (P=0.879) | −0.142 (P=0.144) | +0.127 | 0.027 | 0.255 | β=+ 0.126 |
| Social relationships | +0.319 | +0.624 | +0.054 (P=0.599) | −0.145 (P=0.089) | +0.199 | 0.055 | 0.340 | β=+ 0.194 |
| Environment | +0.319 | +0.517 | +0.077 (P=0.439) | −0.088 (P=0.326) | +0.165 | 0.042 | 0.308 | β=+ 0.167 |
| QoL total | +0.319 | +0.449 | +0.021 (P=0.785) | −0.122 (P=0.063) | +0.143 | 0.033 | 0.260 | β=+ 0.186 |
Path a=effect of predictor on Social Support (controlling for covariates). Path b=effect of Social Support on QoL outcome (controlling for predictors and covariates). Indirect effect=a × b. 95% BC CI=bias-corrected bootstrap confidence interval based on 5,000 resamples. Bold values indicate statistically significant results (P < 0.05). Bold indirect effects indicate that the 95% bias-corrected bootstrap confidence interval excludes zero. Covariates: Age, Gender
Figure 1.
Summary of indirect associations involving perceived social support. Each panel shows the estimated indirect associations involving total perceived social support between each stigma management strategy and QoL domains, based on bootstrap analyses (5,000 resamples). Statistically significant indirect associations are indicated by 95% bias-corrected confidence intervals that exclude zero
Greater secrecy was associated with lower perceived social support (path a = −0.269), and lower perceived social support was associated with poorer QoL across all WHOQOL-BREF domains. Significant indirect associations were observed between secrecy and all QoL outcomes through perceived social support, including overall QoL (indirect effect = −0.108; 95% BC CI: −0.195 to −0.029).
Withdrawal demonstrated the strongest negative association with perceived social support (path a = −0.332). Significant indirect associations were identified for all QoL domains, with the largest observed for the Social Relationships domain (indirect effect = −0.168; 95% BC CI: −0.292 to −0.065).
Education/advocacy showed the strongest positive association with perceived social support (path a = 0.319). Significant positive indirect associations were observed across all QoL domains, with the largest effect for social relationships (indirect effect = 0.199; 95% BC CI: 0.055 to 0.340).
Although preventive telling was positively associated with perceived social support (path a = 0.143), no statistically significant indirect associations with QoL were observed because all bootstrap confidence intervals included zero.
Group comparisons by diagnosis type and gender
Independent samples t-tests were performed to compare QoL domain scores according to diagnosis (CD vs. UC) and sex. As presented in Table 4 and Figure 2, participants with UC reported significantly higher social relationship QoL scores than those with CD (3.59 ± 0.87 vs. 2.95 ± 0.89, P = 0.003), as well as higher overall QoL scores (3.41 ± 0.67 vs. 3.08 ± 0.68, P = 0.030). No statistically significant differences were observed between the two diagnostic groups in physical health, psychological, or environment domains (P > 0.05).
Table 4.
Group comparisons of QoL domains by diagnosis type and gender
| QoL Domain | CD Mean (SD) | UC Mean (SD) | Diff (CD–UC) [95% CI] | Cohen d | P | Male Mean (SD) | Female Mean (SD) | Diff (Male–Female)[95% CI] | Cohen d | P |
|---|---|---|---|---|---|---|---|---|---|---|
| Physical health | 3.01 (0.65) | 3.27 (0.56) | –0.26 [–0.50, –0.02] | –0.42 | 0.18 | 3.35 (0.69) | 3.05 (0.59) | 0.3 [0.01, 0.59] | 0.49 | 0.27 |
| Psychological | 3.20 (0.91) | 3.50 (0.87) | –0.30 [–0.65, 0.05] | –0.34 | 0.06 | 3.57 (0.76) | 3.24 (0.94) | 0.33 [–0.03, 0.69] | 0.37 | 0.02* |
| Social relationships | 2.95 (0.89) | 3.59 (0.87) | –0.64 [–0.99, –0.29] | –0.73 | 0.003* | 3.57 (0.86) | 3.14 (0.92) | 0.43 [0.05, 0.82] | 0.48 | 0.12 |
| Environment | 3.18 (0.89) | 3.31 (0.89) | –0.13 [–0.48, 0.22] | –0.15 | 0.41 | 3.44 (0.85) | 3.16 (0.90) | 0.28 [–0.10, 0.66] | 0.32 | 0.08 |
| QoL total | 3.08 (0.68) | 3.41 (0.67) | –0.33 [–0.60, –0.06] | –0.49 | 0.03* | 3.48 (0.63) | 3.15 (0.69) | 0.33 [0.05, 0.61] | 0.49 | 0.04* |
Note. CD=Crohnʼs Disease (n=58); UC=Ulcerative Colitis (n=44). All QoL domain scores are scaled 1–5. Tests are independent-samples t-tests. *P<0.05, Bold values indicate P < 0.05
Figure 2.
Comparison of mean QoL domain scores (±1 SE) by diagnosis type (CD vs. UC) and gender (male vs. female). Statistically significant differences are indicated (*P <.05, **P <.01)
Male participants reported significantly higher psychological QoL scores than female participants (3.57 ± 0.76 vs. 3.24 ± 0.94, P = 0.028), as well as higher overall QoL scores (3.48 ± 0.63 vs. 3.15 ± 0.69, P = 0.041). No statistically significant sex differences were observed in the physical health, social relationships, or environment domains (P > 0.05).
DISCUSSION
This study examined the relationships between stigma management strategies, social support, and QoL among patients with IBD, including CD and UC, in Saudi Arabia. The findings provide important insights into the psychosocial mechanisms underlying patient well-being and suggest an important role for social support in this context.
The sample was relatively young and demonstrated a notable psychological burden, with a substantial proportion reporting frequent negative emotions. This aligns with previous research indicating that IBD is associated with significant emotional distress due to its chronic, unpredictable course and socially sensitive symptoms.[25,26] The overall moderate QoL observed across domains further supports existing evidence that patients with IBD often experience impaired well-being compared with the general population.[27]
A key finding of this study are the differing associations of stigma management strategies. Education and advocacy emerged as the stigma management strategy most strongly associated with favorable social support and QoL outcomes. This is consistent with prior literature suggesting that active coping and open communication have been associated with lower internalized stigma and better psychosocial outcomes.[28,29] By contrast, concealment-based strategies, such as secrecy and withdrawal, were associated with reduced social support and poorer QoL. These findings align with stigma theory, which posits that avoidance and concealment may be associated with reduced access to supportive resources and greater psychological distress.[30,31]
Bootstrap analyses suggested significant indirect associations involving perceived social support in the relationships between stigma management strategies and QoL. However, these findings should be interpreted with caution because all variables were measured at a single time point. Consequently, the temporal ordering of stigma management strategies, perceived social support, and QoL cannot be established. It is equally plausible that poorer QoL contributes to greater social withdrawal and lower perceived social support, rather than withdrawal leading to poorer QoL. Therefore, these findings should be interpreted as exploratory indirect associations rather than evidence of causal or temporal relationships. Furthermore, validated measures of disease activity were not collected. Since disease activity is a major determinant of psychological well-being, social functioning, and QoL in patients with IBD, residual confounding related to disease severity may have influenced the observed associations.[32,33] Despite this limitation, the observed relationships align with existing literature.[34,35,36] Particularly, preventive telling failed to show significant indirect effects. This suggests that disclosure in isolation is insufficient to enhance QoL; rather, its associations with QoL may vary with the extent of meaningful social engagement. This nuance refines the current understanding by emphasizing the quality and context of disclosure rather than the mere act of sharing one’s diagnosis.[37]
Interestingly, some models revealed statistically significant indirect associations, although their total associations were not significant. This phenomenon, often referred to as an indirect-only effect or suppression pattern, suggests that an indirect link involving perceived social support may exist despite a weak or nonsignificant overall association between the predictor and the outcome and does not necessarily require a significant total effect to be observed before an indirect effect can be identified.[38,39] These findings suggest that perceived social support may represent an important psychosocial pathway linking stigma management strategies and QoL. However, owing to the cross-sectional nature of the study, the current findings should be interpreted as exploratory and not as evidence of causal or temporal relationships.
The strong role of family support observed in this study is particularly relevant within the Saudi cultural context, where collectivist values and close family structures are prominent. Participants reported the highest levels of support from family members, which may be associated with better psychosocial adjustment amid stigma. This is consistent with regional evidence emphasizing the importance of family support in improving health outcomes in Arab populations.[40] However, the persistence of concealment strategies despite high family support suggests that cultural norms surrounding modesty and stigma may still limit open discussion of IBD-related symptoms.[41] The study recruitment strategy should also be considered when interpreting these findings. Participants were recruited through online patient support groups, healthcare networks, and WhatsApp groups, which may have preferentially included individuals who were more socially connected and actively engaged in disease-related communities. Consequently, the relatively high levels of perceived social support observed in this study may not fully represent those of the broader Saudi IBD population.
Patients with UC reported higher social relationships and overall QoL scores than those with CD. Although this finding is consistent with prior literature suggesting that CD often follows a more complex clinical course,[42,43] these differences should be interpreted with caution, given disease activity. Therefore, the observed differences cannot be attributed solely to disease subtype and may have been influenced by unmeasured clinical factors. Similarly, male participants reported higher psychological and overall QoL scores than female participants, consistent with previous studies demonstrating greater psychological distress and poorer QoL among women with IBD. Possible explanations include differences in symptom perception, coping strategies, hormonal influences, and psychosocial burden, all of which may contribute to poorer psychological well-being among women living with IBD.[44,45]
From a clinical perspective, these findings underscore the importance of integrating psychosocial care into routine IBD management. Interventions that promote adaptive stigma management strategies, such as education and advocacy, and enhance social support, may help support patient well-being. Healthcare providers should be encouraged to address stigma-related concerns and facilitate supportive environments that enable patients to openly discuss their condition.
Several limitations should be considered when interpreting these findings. First, the cross-sectional design precludes conclusions regarding causality or temporal relationships; therefore, the observed indirect associations should be interpreted as exploratory rather than causal. Second, participants were recruited using convenience and snowball sampling through online patient support groups, healthcare networks, and WhatsApp groups, which may have introduced selection bias and limited the generalizability of the findings. Third, although the adapted SMSC underwent forward-backward translation, expert review, pilot testing, and demonstrated acceptable internal consistency, comprehensive psychometric validation was not performed. In addition, disease activity and several important clinical characteristics, including biologic therapy, previous surgery, disease location, extraintestinal manifestations, and psychiatric comorbidities, were not collected and may have confounded the observed associations. The relatively modest sample size and the use of multiple statistical tests without formal adjustment for multiple comparisons may also have increased the risk of Type I error. Furthermore, IBD diagnoses were based on participants’ self-report of a previous gastroenterologist diagnosis and were not independently verified through medical records. Finally, all measures were self-reported and may therefore be subject to recall and social desirability bias.
Despite these limitations, this study provides novel evidence regarding the associations among stigma management strategies, perceived social support, and QoL among adults with IBD in Saudi Arabia. Future longitudinal studies with larger, more representative samples, validated disease activity measures, comprehensive clinical data, and fully validated Arabic stigma instruments are needed to confirm these findings.
To summarize, this study identified significant associations between stigma management strategies, perceived social support, and QoL among adults with IBD in Saudi Arabia. Concealment-based strategies, particularly secrecy and withdrawal, were associated with poorer QoL, whereas education and advocacy were associated with better QoL outcomes through significant indirect associations involving perceived social support. Family emerged as the strongest perceived source of social support, highlighting its potential importance within the Saudi cultural context. Although these findings underscore the relevance of psychosocial factors in the care of patients with IBD, they should be interpreted with caution, given the cross-sectional design and the absence of data on disease activity and other important clinical variables. Future longitudinal studies incorporating comprehensive clinical measures are needed to confirm these associations and determine whether interventions targeting stigma management and social support improve patient outcomes.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The author would like to thank all the participants who generously contributed their time and shared their experiences in this study. Appreciation is also extended to the healthcare professionals and patient support groups who facilitated the survey’s distribution. The author is grateful to the Health and Life Center at Taibah University for their support and assistance. Special thanks are extended to Mr. Majed Alhujaili and Mrs. Nourah Alzahrani for their assistance in data collection. The author also expresses sincere appreciation to Dr. Faris Alnezary and Mansour Adam (College of Pharmacy, Taibah University) for their valuable contributions to the data analysis and interpretation of the results. The author acknowledges the use of Grammarly and Paperpal for language editing to enhance clarity and readability.
Funding Statement
Nil.
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