Evaluating the Influence of Diabetes Stigma on Medication Adherence

Diabetes mellitus (DM) is a chronic condition affecting an estimated 422 million adults
worldwide and 28.9 million adults in the US. DM can lead to increased risk of mortality and
significant complications including amputation, blindness, cardiovascular disease, and kidney
damage. The risk of developing these outcomes can be mediated by early diagnosis and
treatment, such as by patient self-management by lifestyle changes and/or taking medication.
However, outcome improvement depends on control of blood glucose levels, which in turn depend
on adherence to treatment. Several psychosocial factors are known to affect treatment
adherence for chronic conditions, one of which is stigma.

Stigma arises when social norms result in the marginalization of people with a certain
identity or trait. Negative stereotypes of people in the stigmatized group result in their
systematic exclusion and/or discrimination. Chronic disease diagnosis itself can lead to the
development of disease-specific identity-based stigma, in that a person's identity is
disrupted by a new label (e.g. "diabetic") applied to them, until they incorporate this new
label into a positive sense of self. Minority stress theory describes the impact of
identity-based marginalization on health outcomes. According to minority stress theory,
discrimination and stigma may lead to heightened stress levels, which can translate over time
into heightened mental and physical health disparities for the stigmatized group. Categories
of stigma experienced by patients include enacted stigma, perceived stigma, self-stigma, and
concealment. Enacted stigma refers to acts of discrimination against people in a stigmatized
group. Perceived stigma refers both to the fear of experiencing enacted stigma, as well as to
the shame resulting from belonging to or being associated with a stigmatized group.
Self-stigma refers to the internalization of negative group stereotypes by members of the
stigmatized group. Concealment, also called non-disclosure, refers to the hiding of a
stigmatized identity or condition.

Stigma has been shown to negatively affect access to care as well as quality of life in
people living with chronic diseases. Disease-specific stigma scales have been developed for
various conditions, including mental illness, HIV/AIDS, epilepsy, and obesity. These scales
have been used to facilitate interventions to minimize negative effects of stigma on health
behaviors and outcomes. In comparison to other health conditions, diabetes stigma has only
recently emerged as a research topic of interest.

DM has been reported to be a health condition that is relatively less stigmatized in
comparison to other conditions. One publication suggested in its introduction that "diabetes
does not appear to have associated stigma." As such, there have been publications comparing
the degree of stigma experienced by DM patients with those with conditions such as
schizophrenia, dementia, HIV, depression, and hypertension. However, numerous qualitative
studies interviewing people with diabetes have revealed that DM patients do experience
significant disease-related stigma.

In the literature, DM-related enacted stigma examples include workplace discrimination
(decreased chance of being hired and increased chance of job loss); threatened or actual
termination of romantic relationships; and judgmental behavior from healthcare professionals.
Likewise, examples of perceived stigma include fear of being characterized as an illicit drug
user when injecting insulin in public; and feelings of isolation when choosing to eat
different foods, particularly in family and cultural situations. Self-stigma and concealment
examples include avoidance of social events; timing self-management so it can be done in
isolation; and altering blood glucose recordings, so as to appear "healthy."

Despite ample evidence of the existence of DM-specific stigma, limited attempts have been
made to measure it. The Diabetes Distress Scale (DDS) was designed to measure "emotional
burden, physician-related distress, regimen-related distress, and…interpersonal distress"
associated with DM. However, the DDS does not comprehensively measure all the types of stigma
minority stress theory has shown to contribute to chronic disease health disparities. The
Barriers to Diabetes Adherence measure includes six questions about stigma, but the scope of
these questions was limited and targeted towards an adolescent population with Type 1 DM. A
limited number of previous publications have adapted disease-specific stigma scales from
other conditions or developed their own questionnaires for said conditions for their diabetes
stigma research needs. To date, only one publication has developed and validated a stigma
scale specifically for DM patients, and this measure only addressed self-stigma. Therefore,
to our knowledge, there is currently no scale that measures multiple facets of DM-specific
stigma that may be contributing to sub-optimal patient diabetes self-management. Given the
relationship between stigma, treatment adherence, and adverse health outcomes for chronic
disease patients, development of a comprehensive DM stigma scale may lead to improvements in
DM patient centered care, which will be addressed by the following Specific Aims:

Specific Aims

1. Develop a novel quantitative measure that comprehensively measures enacted stigma,
perceived stigma, and self-stigma and concealment specific to adult DM patients

2. Pilot the measure with 30-50 DM patients

3. Validate the measure and determine if DM stigma is associated with obesity, diabetes
type, insulin use, and/or is predictive of medication adherence

Inclusion Criteria:

- 18 years of age or older

- Type I or II DM for at least 1 year

- Taking at least 1 medication to manage diabetes

Exclusion Criteria:

- Under 18 years of age

- Non-English speaking