Social stigma in diabetes : a framework to understand a growing problem for an increasing epidemic

Living with chronic obstructive pulmonary disease or type 2 diabetes in Greenland - a qualitative interpretive description study

Non-communicable diseases such as chronic obstructive pulmonary disease (COPD) and type 2 diabetes mellitus (T2D) represent major challenges for health systems all over the world. In an interview study, we explored patient experiences and perspectives of being diagnosed and living with COPD or T2D in Greenland. Participants (n = 24) were selected by purposeful sampling and recruited by phone. We conducted individual semi-structured interviews at the National Hospital in Nuuk and the four regional hospitals. Interviews were audio-recorded, transcribed verbatim, and analysed using interpretive description. Three themes emerged: shock and shame on receiving the diagnosis, coping with a changed life, and varying needs for care and communication. We found that being diagnosed with COPD or T2D required a rapid change in the participants' everyday lives and lifestyle behaviours. Some self-managed their disease well and were able to transfer their knowledge and integrate it into their daily lives, while others struggled to make lifestyle changes. Additionally, living with COPD or T2D could be related to silence and shame. The findings contribute to a better understanding of living with COPD or T2D in the Arctic region and the development of future, culturally-adapted patient education initiatives.

Assigning Responsibility for Depression and Diabetes: Frame Building Factors in Health Coverage

Although frame building is a crucial part of framing in health communication, it is much less understood than media frames or their effects on audiences (i.e. frame setting). To address this research gap, we analyzed the individual, organizational, and external factors of influence contributing to the media's portrayal of responsibility for two major health issues: depression and diabetes. To identify relevant factors, we conducted 23 semi-structured interviews with German journalists who regularly report on these health issues. Our findings indicate that the way in which media coverage portrays responsibilities in depression and diabetes is affected by a variety of factors. These include individual (journalist role perception, journalistic routines, academic background and personal experiences with depression, diabetes-related knowledge, and personal values and beliefs), organizational (editorial lines, space limits, time limitations and payment, and newsroom structures), and external (health news sources, audience interest, newsworthiness, and social norms) factors. Notably, there are differences between depression and diabetes coverage - especially regarding individual factors - confirming that frame building, similar to framing in general, should be examined with regard to specific issues. Nevertheless, some factors that seem important across different topics could be identified.

Make No Apologies: Fear of Negative Evaluation, Depressive Symptoms, and the Mediating Role of Accounting for COVID-Safe Behavior Amongst People at High-Risk for Severe Illness

With the goal of understanding unique and important threats to the mental health of people who are especially vulnerable to severe illness as a result of COVID-19, this study investigated associations between such individuals' fear of negative evaluation, tendency to "account for" practicing COVID-safe behaviors, and depressive symptoms. Grounded in perspectives on self-presentation, normative influence, and cognitive dissonance, we hypothesized that fear of negative evaluation would relate positively to accounting for COVID-safe behaviors, which, in turn, would associate positively with increased depressive symptoms. The results showed that increased fear of negative evaluation predicted an increased use of apologies and excuses, which in turn were positively related to depressive symptoms. Justifications for COVID-safe behaviors were not significantly associated with either fear of evaluation or depressive symptoms. The practical and theoretical implications are discussed.

Impact of Negative or Stigmatizing Messages on Diabetes Outcomes: An Integrative Review

PURPOSE

The purpose was to determine if negative or stigmatizing language and messaging have an impact on diabetes distress, outcomes, or care behaviors in people with diabetes. Since 2012, when the first language position statement was published, the way health care professionals talk to people with diabetes has been an ongoing topic of discussion. However, there have been no recent literature reviews evaluating the impact of problem language on outcomes among people with type 1 and type 2 diabetes.

METHODS

An integrative review was conducted using 4 electronic databases: CINAHL, Embase, Web of Science, and Medline (Ovid). Studies reporting on diabetes, language, stigma, diabetes distress, glycemic outcomes, and self-care behaviors were included.

RESULTS

The review included 9 studies, all of which were of high quality. The impact of negative or stigmatizing language on self-care behaviors was the most commonly addressed outcome. Whereas some studies revealed no change, others reported a decrease in self-care behaviors by people with diabetes who had negative perceptions of provider messages. Actual or perceived use of negative or stigmatizing language is linked to higher A1C. Four studies reported an association between messages and diabetes distress.

CONCLUSIONS

Negative/stigmatizing language has both an immediate and long-term effect on people with diabetes. The inconsistent approaches to studying language in diabetes makes it challenging to compare outcomes and identify themes. Future research is needed to identify effective interventions to change the messages in diabetes.

The impact of stigma on the management of type 1 diabetes: A systematic review

AIMS

To systematically review the literature investigating the links between stigma and the management of type 1 diabetes.

METHODS

A systematic literature review was conducted in accordance with PRISMA guidelines. Both quantitative and qualitative data were considered. Included papers were subject to quality assessment using the Mixed Methods Appraisal Tool (MMAT), and a narrative synthesis of results was reported.

RESULTS

Nineteen articles met the inclusion criteria and were included in the final analysis. Amongst these, one study used mixed methods, nine were qualitative, and nine were quantitative. All studies found a negative relationship between stigma and type 1 diabetes management. Qualitative studies provided a further understanding of the effects observed in the quantitative studies and found that stigma can affect self-care activities, disclosure of diabetes, and the uptake of diabetes technology. Systemic causes of stigma and intersectional stigma were also observed.

CONCLUSIONS

This review highlights that people with type 1 diabetes are negatively affected by stigma, irrespective of their age, gender, culture, or use of diabetes technology. Quantitative studies were limited, in that all studies were cross-sectional, and there was a lack of standardisation across outcome measures. There is a need for interventions to target stigma on both an individual and a systemic level, particularly where people experience multiple intersecting stigmas.

CVOT Summit Report 2023: new cardiovascular, kidney, and metabolic outcomes

The 9th Cardiovascular Outcome Trial (CVOT) Summit: Congress on Cardiovascular, Kidney, and Metabolic Outcomes was held virtually on November 30-December 1, 2023. This reference congress served as a platform for in-depth discussions and exchange on recently completed outcomes trials including dapagliflozin (DAPA-MI), semaglutide (SELECT and STEP-HFpEF) and bempedoic acid (CLEAR Outcomes), and the advances they represent in reducing the risk of major adverse cardiovascular events (MACE), improving metabolic outcomes, and treating obesity-related heart failure with preserved ejection fraction (HFpEF). A broad audience of endocrinologists, diabetologists, cardiologists, nephrologists and primary care physicians participated in online discussions on guideline updates for the management of cardiovascular disease (CVD) in diabetes, heart failure (HF) and chronic kidney disease (CKD); advances in the management of type 1 diabetes (T1D) and its comorbidities; advances in the management of CKD with SGLT2 inhibitors and non-steroidal mineralocorticoid receptor antagonists (nsMRAs); and advances in the treatment of obesity with GLP-1 and dual GIP/GLP-1 receptor agonists. The association of diabetes and obesity with nonalcoholic steatohepatitis (NASH; metabolic dysfunction-associated steatohepatitis, MASH) and cancer and possible treatments for these complications were also explored. It is generally assumed that treatment of chronic diseases is equally effective for all patients. However, as discussed at the Summit, this assumption may not be true. Therefore, it is important to enroll patients from diverse racial and ethnic groups in clinical trials and to analyze patient-reported outcomes to assess treatment efficacy, and to develop innovative approaches to tailor medications to those who benefit most with minimal side effects. Other keys to a successful management of diabetes and comorbidities, including dementia, entail the use of continuous glucose monitoring (CGM) technology and the implementation of appropriate patient-physician communication strategies. The 10th Cardiovascular Outcome Trial Summit will be held virtually on December 5-6, 2024 ( http://www.cvot.org ).

Participants' experiences of attending a structured education course (DAFNEplus) informed by behavioural science

AIMS

As part of a broader process evaluation, we explored participants' experiences of, and engagement with, the DAFNEplus programme's group-based structured education course. This course, which was informed by behavioural science, provided participants with education and instruction to use flexible intensive insulin therapy (FIIT) together with techniques to identify and address unhelpful cognitive and emotional influences on their type 1 diabetes self-management.

METHODS

We interviewed n = 28 DAFNEplus participants. Data were analysed thematically and took account of previous work exploring individuals' experiences of standard DAFNE courses.

RESULTS

As well as benefitting from the DAFNEplus course's skills-based training and educational curriculum, participants' accounts suggested they had experienced cognitive and emotional changes that had positively influenced their confidence and motivation to adopt and sustain the use of FIIT. These benefits were most keenly felt by those who reported negative emotional states and mind-sets pre-course which had made their diabetes self-management challenging. Participants' cognitive and emotional changes were enabled through techniques used during the course to normalise setbacks and imperfect diabetes self-management, capitalise upon group synergies and encourage the use of social support, including from healthcare professionals. Participants also highlighted motivational gains arising from being reassured that diabetes complications are not common or inevitable if a FIIT regimen is followed.

CONCLUSIONS

Our findings suggest that offering training in FIIT, in conjunction with behaviour change techniques that target unhelpful mindsets and emotional resilience, may be more effective in promoting diabetes self-management than offering education and skills training alone.

Disseminating Community-Engaged Research Involving People Experiencing Homelessness and Diabetes Using Participatory Theater

People experiencing homelessness balance competing priorities resulting in reduced capacity to meet the care demands of chronic conditions, including Type 2 Diabetes Mellitus (T2DM). Arts-based performances present an avenue to expose others to these challenges. This article describes the process of incorporating qualitative research findings in a community-based participatory theater production to expose audiences to the day-to-day realities of living with T2DM while simultaneously experiencing homelessness. We conducted five focus groups and two individual interviews with people living with T2DM who had experienced homelessness with guidance from a community-engaged research team. We then collaborated with a local theater company to present common themes from these focus groups in a co-created play about the experience of managing T2DM while being homeless. We performed a staged reading of the play and assessed audience members' perceived stigma through a pre- and post-survey to determine if audience engagement within our theatrical production could reduce stigma toward individuals living with diabetes and/or people experiencing homelessness. This theatrical production is titled "Life Heist: Stealing Hope While Surviving Diabetes and Homelessness." Our work illustrates the feasibility and effectiveness of using participatory theater to disseminate qualitative research findings.

Diabetes-related social stigma among university students in Saudi Arabia: A cross-sectional study

Diabetes-related stigma encompasses stereotypes, discrimination, and blame, significantly influencing diabetes management and overall well-being. Despite high diabetes-related stigma prevalence in various contexts, there is limited research in Saudi Arabia, especially that perceived/enacted by non-diabetics, the so-called social stigma. This cross-sectional study aimed to assess diabetes-related social stigma (DRSS) and to identify correlates among university students in Jazan, Saudi Arabia. A convenience sampling was employed to collect responses from 536 Jazan University students using an online questionnaire. After excluding participants with diabetes mellitus (n = 17), data from 519 individuals were analyzed. The DRSS questionnaire comprised 2 scales: social distancing and negative attitudes and stereotyping. The study found mixed results regarding the student population's attitude toward diabetic patients. Most students displayed favorable answers on social distancing scale statements, with the majority of statements showing willingness to engage in different social aspects with diabetics getting a positive response from at least 96% of respondents. The study identified various types of negative attitudes and stereotyping, for example, 46% of the sample agreed that dealing with a diabetic is upsetting or tiring. Correlates of social distancing included academic year, rural residence, and nonmedical field of specialty, while predictors of negative attitude and stereotyping included female gender and higher family income. The findings indicate a need to improve attitudes related to diabetics among university students in Saudi Arabia, with a particular focus on negative attitude stereotyping. Raising awareness about DRSS, especially among future healthcare professionals, is essential. Further refinement of the DRSS measurement scales is recommended through broader testing among the general population to enhance our understanding of this important issue.

Initial evidence of reliability and validity of an implicit association test assessing attitudes toward individuals who use substances

Background: Substance use disorders (SUDs) are stigmatized conditions, with individual biases driving poor health outcomes. There are surprisingly few validated measures of bias or stigma toward individuals who use substances. Bias can be classified as explicit (self-report) or implicit (behaviorally based).Objectives: The goal of the present study was to establish preliminary indices of reliability and validity of an implicit association test (IAT) designed to measure implicit bias toward individuals who use substances.Methods: A large United States-based, crowd-sourced sample (n = 394, 51.5% male, 45.4% female, 2.5% nonbinary) completed the IAT and a small battery of survey instruments that assessed social distance to mental illness (including heroin use), attitude toward and perceived controllability of injection drug use, perception of public stigma, and social desirability.Results: Nearly all (92%; n = 363) scores on the IAT indicated greater negative than positive attitudes toward those who use substances. Spearman-Brown corrected split-half reliability on the IAT scores was excellent, r = .953. Controlling for social desirability, IAT scores positively correlated with all included measures pertaining to substance use as well as social distance for heroin and schizophrenia (but not diabetes). A principal component analysis resulted in two interpretable components representing disapproval (perceived controllability and negative attitudes) and perceived stigma (social stigma and social distance). Scores on the IAT positively correlated to scores on both components, again, controlling for social desirability.Conclusion: These results provide compelling preliminary evidence of validity of an IAT designed to measure bias toward individuals who use substances.

"Once I take that one bite": the consideration of harm reduction as a strategy to support dietary change for patients with diabetes

BACKGROUND

Despite well-established guidelines to treat diabetes, many people with diabetes struggle to manage their disease. For many, this struggle is related to challenges achieving nutrition-related lifestyle changes. We examined how people with diabetes describe barriers to maintaining a healthy diet and considered the benefits of using a harm reduction approach to assist patients to achieve nutrition-related goals.

METHODS

This is a secondary analysis of 89 interviews conducted with adults who had type 1 or type 2 diabetes. Interviews were analyzed using a content analysis approach. Themes regarding food or diet were initially captured in a "food" node. Data in the food node were then sub-coded for this analysis, again using a content analysis approach.

RESULTS

Participants frequently used addiction language to talk about their relationship with food, at times referring to themselves as "an addict" and describing food as "their drug." Participants perceived their unhealthy food choices either as a sign of weakness or as "cheating." They also identified food's ability to comfort them and an unwillingness to change as particular challenges to sustaining a healthier diet.

CONCLUSION

Participants often described their relationship with food through an addiction lens. A harm reduction approach has been associated with positive outcomes among those with substance abuse disorder. Patient-centered communication incorporating the harm reduction model may improve the patient-clinician relationship and thus improve patient outcomes and quality-of-life while reducing health-related stigma in diabetes care. Future work should explore the effectiveness of this approach in patients with diabetes.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov, NCT02792777. Registration information submitted 02/06/2016, with the registration first posted on the ClinicalTrials.gov website 08/06/2016. Data collection began on 29/04/2016.

Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

Diabetes Care in Humanitarian Settings

Despite the increasing prevalence of diabetes in populations experiencing humanitarian crisis, along with evidence that people living with diabetes are at higher risk for poor outcomes in a crisis, diabetes care is not routinely included in humanitarian health interventions. We here describe 4 factors that have contributed to the inequities and lack of diabetes inclusion in humanitarian programmes: (1) evolving paradigms in humanitarian health care, (2) complexities of diabetes service provision in humanitarian settings, (3) social and cultural challenges, and (4) lack of financing. We also outline opportunities and possible interventions to address these challenges and improve diabetes care among crisis-affected populations.

Attitudes of women with gestational diabetes toward diet and exercise: a qualitative study

OBJECTIVE

Gestational diabetes (GDM) refers to glucose intolerance of varying severity first occurring in pregnancy. Following a diagnosis of GDM, exercise and dietary modification has a positive effect on improving glycemic control. Lifestyle changes affected in pregnancies affected by GDM have beneficial effects on long-term health if continued following birth. In addition, the psychological impact of a diagnosis of GDM should not be overlooked. Reports of maternal stress, anxiety, and fear are commonly reported issues in the literature. Support, both socially and from health care professionals, is also linked with higher rates of success in GDM management. Research to date had focused on women's reaction to a diagnosis of GDM, their mood and quality of life following a diagnosis, and their knowledge or opinions on the management of GDM. This qualitative study explored the attitudes of women with GDM toward these lifestyle changes, specifically diet and exercise. Women were also asked to identify advice that would be useful for other women newly diagnosed with GDM.

METHODS

With ethical approval a qualitative study was conducted using semi-structured interviews which were examined using Thematic Analysis. Patients were invited to participate and gave written consent after a discussion with a study researcher. The question plan for semi-structured interviews was designed with the advice of patient advocates. Recurrent themes were developed until the saturation of data.

RESULTS

Thirty-two women took part in the study. Time, convenience, and lack of educational awareness were common barriers to healthy eating and physical activity plans. Enablers for change included meal planning and organization. Women regarded their diets pre-diagnosis as healthy, with small "tweaks" (such as portion control) required to comply with recommendations. Another significant facilitator to change was support from the woman's partner. This also set a benchmark for plans of diet maintenance within the family structure after pregnancy. Unlike dietary changes, a consistent theme was that exercise was considered a "chore" in managing GDM and was unlikely to be continued in the long term. Practical advice offered by participants for other women with GDM included organization, realistic approaches, and lack of self-blame.

CONCLUSION

Women reported that changes in diet would be more achievable in the long term than changes in exercise patterns. Partners and the clinical team were significant sources of support. Women's views are crucial to providing clinicians with a comprehensive and holistic understanding of disease management. Involving women in self-care decisions and empowering women to manage their own health are key contributors to long-term behavior change as well as service provision and policy implementation.

The Mediating Role of Acceptance Action and Self-Care in Diabetes Self-Stigma's Impact on Type 2 Diabetes Quality of Life: A Cross-Sectional Study

Recently, the quality of life of individuals with diabetes has been reduced, owing to self-stigma that occurs in the process of managing the disease. This process can be improved by accepting diabetes. This study aimed to verify the dual mediating effect of acceptance action and diabetes self-care on the effect of diabetes self-stigma on the quality of life of individuals with type 2 diabetes mellitus (T2DM) in Korea. In this study, 300 of 400 data collected to develop and evaluate health equilibrium tools for individuals with T2DM were randomly selected and analyzed. Data were collected from 1 September 2020 to 31 September 2020 using a structured online questionnaire. For data analysis, descriptive statistics and Pearson's correlation analysis were performed using the Statistical Package for the Social Sciences (SPSS), version 24.0. Additionally, the dual mediation effect was analyzed using PROCESS Macro for SPSS, version 4.1. Acceptance action (B = -0.088, 95% confidence interval [CI], -0.127 to -0.054) and diabetes self-care (B = 0.046, 95% CI, 0.022-0.072) had a mediating effect on the relationship between diabetes self-stigma and quality of life in patients with T2DM in Korea. In particular, these two variables had dual mediating effects (B = 0.017, 95% CI, 0.015-0.019). This study confirmed that diabetes self-care and quality of life can be increased by improving acceptance behavior to overcome the negative impact of self-stigma on the quality of life of patients with T2DM. Establishing a strategy to increase acceptance action as part of an intervention to reduce the negative impact of self-stigma on the quality of life of patients with T2DM is necessary.

(De)Stigmatizing Depression on Social Media: The Role of Responsibility Frames

Responsibility frames on social media could shape recipients' responses toward people with depression, which is crucial for the public (de)stigmatization of the mental disorder. Thus, the present study examines the effects of different responsibility frames (individual, social, combination) in Instagram-posts about depression on respondents' related attributions as well as their emotional and behavioral reactions toward people suffering from the illness. Our online-experiment (N = 1,015) revealed that frames emphasizing the responsibility of one's social network (e.g. family, friends and professionals) for depression, i.e. social frames, strengthened participants' attributions to the social network, i.e. social attributions, most effectively. Individual frames, however, primarily intensified individual attributions to those affected by depression. Contrary to previous findings, a combination frame did not prove to increase recipients' social attributions more than a one-sided social frame. For emotional and behavioral responses, we did not find any effects of responsibility frames compared to the control group-possibly due to buffering effects of the narrative structure of the Instagram posts.

Relationships between personality, emotional well-being, self-efficacy and weight management among adults with type 2 diabetes: Results from a cross-sectional survey

The objective of this study was to examine the associations between personality, general and diabetes-specific well-being and self-efficacy, and weight management indicators, among adults with type 2 diabetes. In addition, to examine whether personality provides incremental explanation of variance in weight management indicators. Australian adults with type 2 diabetes (N = 270; 56% women; age: 61±12 years) were recruited via the national diabetes registry. An online survey included measures of: personality (HEXACO-PI-R), weight management indicators (physical activity, healthy diet, body mass index [BMI]), general well-being (WHO-5), general self-efficacy (GSE), diabetes distress (DDS) and diabetes self-efficacy (DMSES). Analyses included bivariate correlations and linear regression, adjusted for demographic, clinical, and psychological variables. All six personality domains showed significant correlation with at least one weight management indicator: physical activity with extraversion (r = .28), conscientiousness (r = .18) and openness (r = .19); healthy diet with honesty-humility (r = .19), extraversion (r = .24), and agreeableness (r = .14); and BMI with emotionality (r = .20) and extraversion (r = -.20). The strongest associations with general and diabetes-specific well-being and self-efficacy were apparent for extraversion, emotionality and conscientiousness (range: r = -.47-.66). Beyond covariates, personality domains explained additional variance for physical activity (Adjusted R2 = .31, R2 difference = .03, p = .03; openness: β = .16, p = .02, emotionality: β = .15, p = .04) and healthy diet (Adjusted R2 = .19, R2 difference = .03, p = .02; honesty-humility: β = .20, p = .002, extraversion: β = .19, p = .04) but not BMI. This study shows that personality is associated with weight management indicators and psychological factors among adults with type 2 diabetes. Further research is needed, including objective measurement of weight management indictors, to examine how personality influences the experience of type 2 diabetes.

Prevalence and predictors of perceived COVID-19 stigma within a population-based sample of adults with COVID-19

BACKGROUND

Growing evidence suggests that individuals with COVID-19 face stigmatization, which is associated with poor health outcomes and behaviors. However, very few population-based studies have examined risk factors for experiencing COVID-19 stigma. This study examined prevalence and predictors of perceived COVID-19 stigma using a population-based probability sample of adults with COVID-19.

METHODS

We included adults with polymerase chain reaction-confirmed SARS-CoV-2 in Michigan between January 1, 2020 and July 31, 2021. Perceived COVID-19 stigma was considered present if a respondent answered affirmatively to any of the following items due to people thinking they might have COVID-19: "you were treated badly," "people acted as if they were scared of you," and "you were threatened or harassed." We conducted modified Poisson regression with robust standard errors to estimate associations between perceived COVID-19 stigma and potential predictors, including sex, age, race and ethnicity, household income, education, employment, smoking status, body mass index, preexisting diagnosed physical or mental comorbidities, and COVID-19 illness severity.

RESULTS

Perceived COVID-19 stigma was commonly reported among our respondents (38.8%, n = 2,759). Compared to those over 65 years, respondents who were 18 - 34 (adjusted prevalence ratio (aPR): 1.41, 95% confidence intervals (CI): 1.12 - 1.77) and 35 - 44 years old (aPR: 1.66, 95% CI: 1.31 - 2.09) reported higher perceived stigma. Female respondents had 1.23 times higher prevalence of perceived COVID-19 stigma (95% CI: 1.10 - 1.37) than male respondents and non-Hispanic Black respondents had 1.22 times higher prevalence of perceived COVID-19 stigma (95% CI: 1.04 - 1.44) than non-Hispanic White respondents. Moreover, respondents with pre-existing diagnosed psychological or psychiatric comorbidities were more likely to report perceived COVID-19 stigma (aPR: 1.29, 95% CI: 1.13 - 1.48) compared to those without diagnosed comorbidities. Respondents with very severe COVID-19 symptoms were also more likely to report perceived COVID-19 stigma (aPR: 1.47, 95% CI: 1.23 - 1.75) than those with asymptomatic or mild symptoms.

CONCLUSIONS

We found that populations who are marginalized in United States, such as females, non-Hispanic Black adults, or individuals with chronic conditions, are more likely to report perceived COVID-19 stigma. Continuing to monitor COVID-19 stigma, especially in vulnerable populations, may provide useful insights for anti-stigma campaigns and future pandemics.

Influence of dialysis-related stigma on health-related indicators in Japanese patients undergoing hemodialysis

INTRODUCTION

Focusing on impacts to health-related indicators in older Japanese patients, this study analyzed both the direct influence of dialysis-related stigma and influences of its intersectionality with other stigmatized characteristics.

METHODS

Data were collected through a cross-sectional survey of 7461 outpatients in dialysis facilities. Other stigmatized characteristics include lower income, lower education, disabled activities of daily living, and diabetic end-stage renal disease (ESRD) as a cause for starting dialysis treatment.

RESULTS

The average rate of an "agree" response on dialysis-related stigma items was 18.2%. Dialysis-related stigma significantly influenced all three health-related indicators, including suspected depression, informal networks, and compliance with dietary therapy. In addition, each interaction between dialysis-related stigma and educational attainment, gender, and diabetic ESRD significantly influence one health-related indicator.

CONCLUSION

These results suggest that dialysis-related stigma has both a significant direct and synergic influence with other stigmatized characteristics on health-related indicators.

Experiences of stigma, psychological distress, and facilitative coping among pregnant people with gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has been rising in the United States, and it poses significant health risks to pregnant individuals and their infants. Prior research has shown that individuals with GDM also experience prevalent stress and mental health issues, which can further contribute to glucose regulation difficulties. Stigma associated with GDM may contribute to these mental health challenges, yet there is a lack of focused research on GDM-related stigma, its impact on psychological health, and effective coping mechanisms. Thus, this qualitative study aims to understand individuals' experiences related to GDM stigma, mental health, and facilitative coping.

METHODS

In-depth, semi-structured interviews were conducted with 14 individuals with a current or recent (within the last year) diagnosis of GDM. Thematic analysis was employed to guide data analysis.

RESULTS

Four themes emerged from data analysis: (1) experience of distal GDM stigma including stigmatizing provider interactions, stigma from non-medical spaces, and intersecting stigma with weight, (2) internalized GDM stigma, such as shame, guilt, and self-blame, (3) psychological distress, which included experiences of stress and overwhelm, excessive worry and fear, and loneliness and isolation, and (4) facilitative coping mechanisms, which included diagnosis acceptance, internet-based GDM community, active participation in GDM management, social and familial support, and time for oneself.

CONCLUSIONS

Findings demonstrate the relevance of GDM stigma in mental health among people with GDM and the need for addressing GDM stigma and psychological health in this population. Interventions that can reduce GDM stigma, improve psychological wellness, and enhance positive coping may facilitate successful GDM management and healthy birth outcomes. Future quantitative, theory-driven research is needed to understand the prevalence of GDM stigma experiences and mechanisms identified in the current study, as well as among marginalized populations (e.g., individuals of color, sexual and gender minorities).

Person-first language in diabetes and obesity scientific publications

AIMS

We aimed to quantify the use of person-first language (PFL) among scholarly articles focusing on diabetes or obesity.

METHODS

PFL and condition-first language (CFL) terms for diabetes and obesity (e.g. diabetic, obese) were identified from existing guidelines and a review of the literature. Exact phrase literature searches were conducted between 2011 and 2020 and results were categorised as PFL, CFL or both.

RESULTS

Among diabetes articles, 43% used PFL, 40% used CFL and 17% contained both. Among obesity articles, 0.5% used PFL, 99% used CFL and 0.2% used both. The use of PFL increased by 3% per year for diabetes articles, compared to 117% for obesity articles. The rate of adoption of PFL in diabetes articles was unchanged in 2018-2020 compared to the 3 years prior.

CONCLUSIONS

While the use of person-first language in diabetes articles had increased over the review period, its rate of adoption has started to slow. Conversely, the use of PFL in obesity articles is nascent and increasing.

Stigma, Self-Care, and Intuitive Eating in Black Americans with Type 2 Diabetes

Type 2 diabetes is prevalent among Black Americans. Stigma associated with type 2 diabetes, both in general and specific to weight, is damaging to self-care, which is crucial for the effective management of diabetes. Family relationships may buffer the negative impact of stress, especially among Black Americans who have historically relied on informal support networks. Our goal was to investigate how type 2 diabetes stigma (H1) and weight stigma (H2) were related to self-care and intuitive eating - a non-restrictive approach to nutrition; H3 predicted that family relationship satisfaction would moderate the relationships predicted in H1 and H2. Black Americans diagnosed with type 2 diabetes (N = 225) were recruited via Qualtrics panels to complete an online survey of self-report measures. We used multiple linear regression to test our hypotheses. Both chronic illness and weight stigma were related as predicted to one subscale of intuitive eating (eating for physical hunger). Our moderation analyses revealed that family relationship satisfaction was protective against the harms of stigma at moderate to high levels. Intuitive eating is a promising non-restrictive treatment option for type 2 diabetes.

Identification of Sociodemographic and Clinical Factors Influencing the Feeling of Stigmatization in People with Type 1 Diabetes

BACKGROUND

A large percentage of people with type 1 diabetes experience stigma, which may directly affect diabetes management. Moreover, it may adversely influence the acceptance of the disease and, thus, the treatment process, including compliance with medical and dietary recommendations. Therefore, it is important to seek adequate forms of counteracting the phenomenon of stigmatization. Thus, the aim of the study was to determine the factors influencing the level of perceived stigma by T1D patients, with particular emphasis on sociodemographic factors (including sex, place of residence, and education) and clinical factors related to the course of the disease.

METHODS

An observational cross-sectional online questionnaire was conducted in a group of 339 people with T1D. The link to the questionnaire was shared via social media. The DSAS-1 questionnaire translated into Polish was used as the research tool.

RESULTS

A moderate level of stigmatization was found (49.78 ± 14.54 points). It was significantly lower in people living in small towns compared to rural residents (ß = -0.121, p = 0.038), lower in people in relationships compared to those who are single (ß = -0.175, p = 0.001), in people diagnosed with T1D at an older age (ß = -0.107, p = 0.048), and in those who rated their financial situation as very good vs. bad (ß = -0.314, p < 0.001). It was also found that the level of stigma significantly decreased with age (ß = -0.181, p = 0.001). In addition, a significantly higher stigma perception was uncovered in the group of people with HbA1C > 7% than in the group ≤ 7% (ß = 0.118, p = 0.030).

CONCLUSIONS

Due to the occurrence of stigma among people with T1D, which can directly affect the management of diabetes, effective and comprehensive efforts should be made to provide support to people with diabetes. It is also necessary to raise awareness among the general public and disseminate knowledge about diabetes, which can reduce stigmatization as a result. Anti-stigma messages should be included in the prevention programs about the potential side effects and risks associated with mistreating people with T1D.

Measuring public attitudes towards people living with chronic diseases in Arabic-speaking populations: adaptation and development of the Social Stigma Scale of Chronic Diseases (SSS-CD)

BACKGROUND

A large proportion of the population in Arab countries suffer from chronic diseases. According to the statistics by the Global Health Estimates, chronic illnesses contribute by 71% to total deaths in the Arab region. While chronic illnesses have been demonstrated to carry high levels of social stigma, it is only recently that little research attention has been given to this topic in the Arab world. It is well-established that the social stigma construct is culturally-dependent. Therefore, the lack of an Arabic measure highlighted the urgent need for developing a culturally adapted and valid instrument to assess social stigma toward people living with chronic diseases. In this study, we aimed to examine the psychometric properties of the Arabic translation, adaptation and development of "the Social Stigma Scale of Chronic Diseases" (SSS-CD).

METHOD

Fifteen items derived from the literature and assessing social stigma towards chronic diseases have been administered to 570 Arabic-speaking adults from the Lebanese general population (aged 24.59 ± 6.75years; 68.6% women). Items were translated into Arabic using a forward-backward translation method. Exploratory factor analysis (EFA) using a principal-axis EFA on the first split-half subsample, followed by a confirmatory factor analysis (CFA) tested on the model extracted from the EFA on the second split-half subsample, were conducted to examine the construct validity of the SSS-CD. Fit indices were deemed adequate if the normed model chi-square (χ²/df) ≤ 3, the Steiger-Lind root mean square error of approximation (RMSEA) ≤ 0.08, the Tucker-Lewis Index (TLI) and the comparative fit index (CFI) ≥ 0.90.

RESULTS

Findings revealed that the 10-item SSS-CD has a unidimensional factor structure, with the following fit indices: χ²/df = 92.95/34 = 2.73, RMSEA = 0.077 (90% CI 0.059, 0.096), SRMR = 0.062, CFI = 0.939, TLI = 0.919. A good internal consistency was demonstrated by a McDonald's omega value of 0.73 for the total score. Findings also supported invariance across gender, with men exhibiting higher levels of social stigma attached to chronic diseases than women. All three dimensions of stigmatization (social, psychological and evolutionary stigmatization) were positively correlated with SSS-CD scores (Social self-interest [r = .40; p < .001], Evolutionary self-interest [r = .37; p < .001], Psychological self-interest [r = .42; p < .001]), demonstrating relatively strong convergent validity.

CONCLUSION

Our findings suggest that the SSS-CD has robust psychometric qualities. We thus preliminarily suggest that the scale is valid, reliable and suitable for use among Arabic-speaking people from the general population to measure public attitudes towards people living with chronic diseases. Providing this psychometrically sound measure will hopefully enable to foster research in this area in order to draw a clear overview of the prevalence and characteristics of social stigma attached to chronic diseases in Arabic-speaking communities. However, given that this was the first study to examine the psychometric properties of the SSS-CD, the present findings and conclusions should be considered tentative pending future cross-national validation studies.

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

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.

Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease

Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.

Reducing social diabetes distress with a conversational agent support system: a three-week technology feasibility evaluation

Background

People with diabetes mellitus not only have to deal with physical health problems, but also with the psycho-social challenges their chronic disease brings. Currently, technological tools that support the psycho-social context of a patient have received little attention.

Objective

The objective of this work is to determine the feasibility and preliminary efficacy of an automated conversational agent to deliver, to people with diabetes, personalised psycho-education on dealing with (psycho-)social distress related to their chronic illness.

Methods

In a double-blinded between-subject study, 156 crowd-workers with diabetes received a social help program intervention in three sessions over three weeks. They were randomly assigned to receive support from either an interactive conversational support agent (n=79) or a self-help text from the book "Diabetes burnout" as a control condition (n=77). Participants completed the Diabetes Distress Scale (DDS) before and after the intervention, and after the intervention, the Client Satisfaction Questionnaire (CSQ-8), Feeling of Being Heard (FBH), and System Usability Scale (SUS).

Results

Results indicate that people using the conversational agent have a larger reduction in diabetes distress (M=-0.305, SD=0.865) than the control group (M=0.002, SD=0.743) and this difference is statistically significant (t(154)=2.377, p=0.019). A hypothesised mediation effect of "attitude to the social help program" was not observed.

Conclusions

An automated conversational agent can deliver personalised psycho-education on dealing with (psycho-)social distress to people with diabetes and reduce diabetes distress more than a self-help book.

Ethics Study Registration and Open Science

This study has been preregistered with the Open Science Foundation (osf.io/yb6vg) and has been accepted by the Human Research Ethics Committee - Delft University of Technology under application number 1130. The data and analysis script are available: https://surfdrive.surf.nl/files/index.php/s/4xSEHCrAu0HsJ4P.

Type 2 diabetes stigma and its association with clinical, psychological, and behavioral outcomes: a systematic review and meta-analysis

AIM

To synthesize quantitative research evidence on the association between type 2 diabetes (T2D) stigma and psychological, behavioral, and clinical outcomes.

METHODS

We searched APA PyschInfo, Cochrane Central, Scopus, Web of Science, Medline, CINAHL and EMBASE through November 2022. Peer-reviewed observational studies examining the association between T2D stigma and psychological, behavioral, and/or clinical outcomes were eligible for inclusion. Risk of bias was assessed with the JBI critical appraisal checklist. Correlation coefficients were pooled in random effect meta-analyses.

RESULTS

Our search produced 9642 citations, 29 met the inclusion criteria. Included articles were published between 2014 and 2022. We found a weak positive correlation between T2D stigma and HbA1C (r=0.16, 95% CI:0.08 to 025, I²=70%, N=7 studies), a moderate positive correlation between T2D stigma and depressive symptoms (r=0.49, 95% CI: 0.44 to 0.54, I²=26.9%, n=5 studies) and diabetes distress (r=0.54, 95% CI: 0.35 to 0.72, I²=96.9%, n=7studies). Persons with T2D stigma who experienced stigma tended to have less engagement in diabetes self-management, though this association was weak (r=-0.17, 95% CI: -0.25 to -0.08, I²=79.8%, n=7studies).

CONCLUSIONS

T2D stigma was associated with negative health outcomes. Further studies are required to disentangle the underlying causal mechanisms to inform the development of appropriate stigma-reduction interventions.

Risk reduction intervention for raised blood pressure (REVERSE): protocol for a mixed-methods feasibility study

INTRODUCTION

Around 40% of adults have pre-hypertension (blood pressure between 120-139/80-89), meaning they are at increased risk of developing hypertension and other cardiovascular disease-related conditions. There are limited studies on the management of pre-hypertension; however, guidance recommends that it should be focused on lifestyle modification rather than on medication. Self-monitoring of blood pressure could allow people to monitor and manage their risk status and may allow individuals to modify lifestyle factors. The purpose of this study is to determine the feasibility and acceptability, to both healthcare professionals and people with pre-hypertension, of blood pressure self-monitoring.

METHODS AND ANALYSIS

A prospective, non-randomised feasibility study, with a mixed-methods approach will be employed. Eligible participants (n=114) will be recruited from general practices, pharmacies and community providers across Lancashire and South Cumbria. Participants will self-monitor their blood pressure at home for 6 months and will complete questionnaires at three timepoints (baseline, 6 and 12 months). Healthcare professionals and participants involved in the study will be invited to take part in follow-up interviews and a focus group. The primary outcomes include the willingness to engage with the concept of pre-hypertension, the acceptability of self-monitoring, and the study processes. Secondary outcomes will inform the design of a potential future trial. A cost-analysis and cost-benefit analysis will be conducted.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from London-Fulham NHS Research Ethics Committee, the University of Central Lancashire Health Ethics Review Panel and the HRA. The results of the study will be disseminated via peer-reviewed publications, feedback to service users and healthcare professionals, and to professional bodies in primary care and pharmacy.

TRIAL REGISTRATION NUMBER

ISRCTN13649483.

Relationship between the insulin use and stigma in type 2 diabetes mellitus

AIMS

This study aimed to investigate the relationship between insulin use and stigma in Type 2 Diabetes Mellitus (T2DM).

METHODS

The study was carried out in the endocrinology and metabolic disorders outpatient clinic of a state hospital between February and October 2022. The study was carried out with 154 patients, 77 of them were treated with insulin while 77 were treated with peroral antidiabetic drugs (PAD). The patient identification form and Type 2 Diabetes Stigma Assessment Scale (DSAS-2) were used for data collection. The data were analyzed by using IBM SPSS 26.0 software.

RESULTS

DSAS-2 total score, treated differently, blame and judgment, and self-stigma subscales were higher in insulin-treated T2DM patients compared to the patients treated with PAD. There was a positive relationship between the number of daily injections and the DSAS-2 total score (r = 0.554). Multiple linear regression showed that type of the treatment, treatment duration, number of daily injections and perceived level of health were the determinants of the DSAS-2 score.

CONCLUSIONS

Stigma was high in insulin-treated T2DM patients and as the number of daily injections increased, the level of the perceived stigma increased. We recommend considering the high level of perceived stigma in insulin-treated T2DM patients while preparing nursing investigations.

Social exclusion in people with diabetes: cross-sectional and longitudinal results from the German Ageing Survey (DEAS)

As social exclusion can be linked to worse health and overall reduced quality of life, we describe social exclusion in people with diabetes and assess whether diabetes can be considered as a risk factor for social exclusion. We analyzed two waves (2014, 2017, N = 6604) from a survey of community-dwelling people aged > 40 using linear regression, group comparison and generalized estimating equations to explore the association between diabetes, social exclusion, socioeconomic, physical and psychosocial variables. In the entire cohort, diabetes was cross-sectionally associated with social exclusion after adjusting for covariates (p = 0.001). In people with diabetes, social exclusion was further associated with self-esteem (p < 0.001), loneliness (p =  < 0.001), income (p = 0.017), depression (p = 0.001), physical diseases (p = 0.04), and network size (p = 0.043). Longitudinal data revealed that higher levels of social exclusion were already present before the diagnosis of diabetes, and future social exclusion was predicted by self-esteem, loneliness, depression, and income, but not by diabetes (p = .221). We conclude that diabetes is not a driver of social exclusion. Instead, both seem to co-occur as a consequence of health-related and psychosocial variables.

The influence of weight on psychosocial well-being in diabetes

BACKGROUND

Individuals with diabetes experience a wide variety of psychosocial responses to their illness due, in part, to the nature of type 1 and type 2 diabetes. Variation in patient weight may play a central role in these differences, yet its influence on psychosocial variation is largely unknown. The current study investigates the relationship between patients' perceived weight status and aspects of psychosocial well-being among individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D).

METHODS

Individuals who were diagnosed with type 1 or type 2 diabetes were assessed via an online survey from the Diabetes, Identity, Attributions, and Health Study. Participants were categorized into a lower v. higher weight status group based on their self-reported perceived weight. Analyses of covariance were conducted to assess differences in measures of disease onset blame, diabetes stigma, and identity concerns among diabetes type and perceived weight status. Covariates included in our models were gender, age, education, and time since diagnosis. Bonferroni correction was used for post-hoc tests to assess any significant interactions found in our models.

RESULTS

Findings indicated that weight moderates multiple psychosocial outcomes pertinent to illness experience. Those with T2D and lower weight blamed themselves less for their disease onset, while those with higher weight felt blamed more for their disease onset by others, regardless of diabetes type. Individuals with T1D and higher weight were more frequently and more concerned about being mistaken for having the other disease type (i.e., T2D) compared to those with lower weight.

CONCLUSIONS

Weight is a key influence on the psychosocial outcomes for people with diabetes, but it operates differently in type 1 versus type 2 diabetes. By further examining the unique interaction between disease type and weight status we may be able to improve psychological well-being among affected individuals of all sizes.

Development and Validation of a Diabetes Questionnaire for Middle School Students

OBJECTIVE

To develop and validate a questionnaire to assess diabetes knowledge, attitudes, beliefs, and intent to change among middle school students.

DESIGN

A cross-sectional validation analysis.

SETTING

Students in 3 urban middle schools in Utah participated in this study.

PARTICIPANTS

The 25-item questionnaire was validated in independent samples of 277 and 304 students in the seventh and eighth grades.

VARIABLES MEASURED

The questionnaire includes the following variables: diabetes knowledge, attitudes, beliefs, and intent to change dietary and physical activity behaviors.

ANALYSIS

Rigorous statistical approaches, including Cronbach's α (goodness of fit) calculation, test-retest reliability, and exploratory and confirmatory factor analyses, were employed to examine the reliability and construct validity.

RESULTS

The Cronbach's α coefficients were 0.7 for both subscales demonstrating acceptable internal consistency. All factor loadings were > 0.4, revealing close relations between factors and items. The confirmatory factor analysis model fit was 0.9 for the comparative fit index and Tucker-Lewis Index, indicating a reasonable model-data fit.

CONCLUSIONS AND IMPLICATIONS

This study demonstrated the validity of a diabetes questionnaire for middle school students. Future work is needed to validate its use in a diabetes prevention program, given the growing need for diabetes education among young adolescents.

Effectiveness of a diabetes educational intervention at primary school

Background

Brazil ranks fifth in the world in the number of adults with diabetes, and third for type 1 diabetes. Conducting educational actions on this topic in public schools in this country is extremely important, since it can assist in the early adoption of good life habits and in a better care for students in this condition.

Objective

The aim of this study was to assess the effectiveness of an educational intervention about diabetes for students and school staff.

Methods

This is an interventional non-randomized longitudinal study, in which interviews were conducted before and after a playful intervention with the use of theater play and games for students and plus a training for the school staff.

Results

A total of 89 participants completed the study, being 73 students aged 7 to 12 years old, and 16 school staff. As a result, there was a positive change in knowledge and perception of diabetes by the students. The greatest changes in the answers among the participants, at the post-intervention period, were related to the possibility of consuming something with sugar by those with diabetes, and particularly how to cope in hypoglycemia situations by the school staff.

Conclusions

Actions like these must be encouraged within the school environment, especially in countries with high prevalence of diabetes.

Association of self-stigma with glycated hemoglobin: A single-center, cross-sectional study of adults with type 1 diabetes in Japan

AIMS/INTRODUCTION

There has been an increase in research on diabetes-related stigma and its association with glycated hemoglobin (HbA1c) over the past years. However, little is known about the association of self-stigma with HbA1c in persons with type 1 diabetes. This study aims to examine the association between self-stigma and HbA1c in Japanese people with type 1 diabetes.

MATERIALS AND METHODS

This cross-sectional study was conducted at a clinic in Tokyo. Questionnaires using nine items from the Japanese version of the Self-Stigma Scale was distributed to outpatients with type 1 diabetes, aged ≥18 years. We excluded outpatients with serious mental disorder, those who required urgent medical treatment or received hemodialysis. Adjusted linear regression analyses tested the association between the score of the 9-item Self-Stigma Scale and HbA1c.

RESULTS

Questionnaires were distributed to 166 eligible participants. A total of 109 participants were included in the final analysis after excluding participants with incomplete answers and laboratory data. After adjusting for age, sex, employment status, body mass index, duration of diabetes and insulin secretion, there was a significant positive association between self-stigma and HbA1c (β = 0.05, 95% confidence interval 0.01 to 0.08).

CONCLUSIONS

This cross-sectional study showed a significant association between self-stigma and HbA1c in persons with type 1 diabetes. Addressing self-stigma might be as equally essential as measuring HbA1c in evaluating glycemic outcome among individuals with type 1 diabetes.

A Spanish-language translation for the U.S. of the type 2 diabetes stigma assessment scale (DSAS-2 Spa-US)

Background

Diabetes stigma is recognized to negatively impact health-related outcomes for people living with type 2 diabetes (T2D), but there is a dearth of evidence among U.S. Latino adults with T2D. Our aim was to develop a Spanish-language translation of the Type 2 Diabetes Stigma Assessment Scale (DSAS-2) and examine its psychometric properties among U.S. Latino adults with T2D.

Methods

The translation was developed through a multi-step process, including a focus group with community health workers (n=5) and cognitive debriefing interviews with Latino adults with T2D (n=8). It was field-tested in an online survey of U.S. Latino adults with T2D, recruited via Facebook (October 2018 to June 2019). Exploratory factor analysis examined structural validity. Convergent and divergent validity were assessed by testing hypothesized correlations with measures of general chronic illness stigma, diabetes distress, depressive and anxiety symptoms, loneliness, and self-esteem.

Results

Among 817 U.S. Latino adults with T2D who participated in the online survey, 517 completed the Spanish-language DSAS-2 (DSAS Spa-US) and were eligible for the study (mean age 54 ± 10 years, and 72% female). Exploratory factor analysis supported a single-factor solution (eigenvalue=8.20), accounting for 82% of shared variance among the 19 items, all loading ≥ 0.5. Internal consistency reliability was high (α=0.93). As expected, strong, positive correlations were observed between diabetes stigma and general chronic illness stigma (rs=0.65) and diabetes distress (rs=0.57); medium, positive correlations, between diabetes stigma and depressive (rs=0.45) and anxiety (rs=0.43) symptoms, and loneliness (rs=0.41); and a moderate negative correlation between diabetes stigma and self-esteem (rs=-0.50). There was no relationship between diabetes stigma and diabetes duration (rs=0.07, ns).

Conclusion

The DSAS-2 Spa-US is a version of the DSAS-2, translated into Spanish, that has good psychometric properties for assessing diabetes stigma in U.S. Latino adults with T2D.

Diabetes-related shame among people with type 2 diabetes: an internet-based cross-sectional study

INTRODUCTION

Emerging evidence suggests that diabetes stigma and negative emotions associated with it may impair the quality of life of people with diabetes. Among these psychological distresses, shame is considered the most distressing of all human emotional experiences and may be a condition to which diabetes clinicians should pay attention. This epidemiological study focused on diabetes-related shame and aimed to determine the prevalence of diabetes-related shame, its factors, and its association with psychological indicators.

RESEARCH DESIGN AND METHODS

A cross-sectional online survey was conducted among people with type 2 diabetes preregistered with a research firm. The questionnaire included experience of diabetes-related shame and demographic data such as age, clinical characteristic measures such as hemoglobin A1c (HbA1c), and psychological indicators, including the WHO Five Well-Being Index (WHO-5) and Problem Areas In Diabetes-5 (PAID-5). Differences in each indicator between people with diabetes who experienced shame and those who did not were analyzed with the unpaired t-test. As supplemental analysis, binomial logistic regression analysis was used to identify factors associated with the prevalence of diabetes-related shame.

RESULTS

Of the 510 participants, 32.9% experienced diabetes-related shame and 17.5% concealed their disease from colleagues or friends. Those who had experienced diabetes-related shame showed significantly lower WHO-5 and higher PAID-5 scores (p<0.001). However, no significant difference was found in HbA1c (p=0.36). Binomial logistic regression revealed that women, young adults, those without a college degree, those with low self-efficacy, and those with a strong sense of financial burden or external pressure were at higher risk of experiencing diabetes-related shame.

CONCLUSIONS

Among people with type 2 diabetes mellitus, diabetes-related shame was associated with diabetes-specific emotional distress and low psychological well-being. Further research and care development are needed to address diabetes-related shame and improve the quality of life of people with diabetes.

Deciphering Latent Health Information in Social Media Using a Mixed-Methods Design

Natural language processing techniques have increased the volume and variety of text data that can be analyzed. The aim of this study was to identify the positive and negative topical sentiments among diet, diabetes, exercise, and obesity tweets. Using a sequential explanatory mixed-method design for our analytical framework, we analyzed a data corpus of 1.7 million diet, diabetes, exercise, and obesity (DDEO)-related tweets collected over 12 months. Sentiment analysis and topic modeling were used to analyze the data. The results show that overall, 29% of the tweets were positive, and 17% were negative. Using sentiment analysis and latent Dirichlet allocation (LDA) topic modeling, we analyzed 800 positive and negative DDEO topics. From the 800 LDA topics—after the qualitative and computational removal of incoherent topics—473 topics were characterized as coherent. Obesity was the only query health topic with a higher percentage of negative tweets. The use of social media by public health practitioners should focus not only on the dissemination of health information based on the topics discovered but also consider what they can do for the health consumer as a result of the interaction in digital spaces such as social media. Future studies will benefit from using multiclass sentiment analysis methods associated with other novel topic modeling approaches.

A WHO key informant language survey of people with lived experiences of diabetes: Media misconceptions, values-based messaging, stigma, framings and communications considerations

AIMS

This study aimed to learn from people with lived experiences of diabetes to raise the quality of diabetes communications.

METHODS

An online key informant survey for people (18+) with a direct and/or adjacent (caregiver, friend, family-member etc.,) lived experience of diabetes. Through thematic analysis, we gathered insights on perceptions of media reporting on diabetes and communicating with accuracy, impact and without stigma. Descriptive analysis also investigated effective values for WHO to communicate diabetes with key audiences of policy-makers, funding partners and the general public.

RESULTS

918 respondents in 58 WHO Member States were analysed. Participants identified five key themes requiring more appropriate consideration in the media: accurately defining diabetes types, over-emphasis on sugar and lifestyle, negative impacts of diabetes stigma, burden of costs (financial, personal and interpersonal) and mental health. Irrespective of audience, key values-based messages identified as important for WHO to convey included: 'urgency', 'preventing suffering', 'improving wellbeing' and 'meaningful engagement' of people with lived experience.

CONCLUSION

Learning from people with lived experience of diabetes identifies key diabetes communication considerations. Continued meaningful engagement of this group, including in WHO's work and the multistakeholder diffusion of this methodology to local contexts, could improve public discourse on diabetes and related policies.

Type 2 Diabetes Stigma Assessment Scale (DSAS-2): Cultural and linguistic adaptation and psychometric assessment of the Arabic version

AIMS

To culturally and linguistically adapt the Type 2 Diabetes Stigma Assessment Scale (DSAS-2) into Arabic and assess its psychometric properties.

METHODS

Following forward-backward translation of the DSAS-2, the Content Validity Index (CVI) was assessed. Cognitive debriefing and pilot testing were conducted with adults with T2DM. The Arabic DSAS-2 was included in a multi-center, cross-sectional study (N = 327) Arabic-speaking adults with type 2 diabetes. Psychometric analyses included exploratory and confirmatory factor analysis (EFA/CFA), internal consistency reliability, and convergent validity.

RESULTS

The Arabic DSAS-2 was considered appropriate, with an excellent CVI (0.98). Unforced EFA revealed a satisfactory three-factor structure, indicating the same subscales as the original instrument ('Treated differently', 'Blame and judgment', 'Self-stigma'). EFA for three factors showed good indicators (KMO=0.924; Bartlett's test of sphericity χ2 = 4063.709, df=171, p &lt; 0.001). Internal consistency was satisfactory for both the three-factor structure (α = 0.91, α = 0.88, and α = 0.88, respectively) and the single factor (α = 0.94). CFA results were inconclusive. Although fit indices improved for the single-factor model, compared to the three-factor, they remained inadequate. The total scale demonstrated satisfactory convergent validity with self-esteem.

CONCLUSIONS

The Arabic DSAS-2 has excellent reliability and acceptable validity, supporting a three-factor structure as well as the use of a total score.

The stigma associated with gestational diabetes mellitus: A scoping review

BACKGROUND

Gestational diabetes mellitus (GDM) affects an increasing number of pregnant women globally. Although studies have identified psychosocial ramifications associated with GDM, stigma in the form of experienced discrimination and self-blame and its consequences have received limited attention. Our objective was to examine the current evidence on stigma, as experienced among women with GDM, including the potential adverse consequences hereof.

METHODS

A scoping review was conducted with citations retrieved from the databases MEDLINE, CINAHL, EMBASE and, PsycINFO. Studies published before 15 June 2022, when the search was conducted, were included.

FINDINGS

We identified 1388 citations and included 44 in the review. We found that women with GDM may experience stigma in the form of overt discrimination from healthcare personnel and relatives, and in the form of internalised stigma, such as guilt and shame. Identified consequences include avoidance of screening, not following dietary recommendations nor reporting blood glucose readings, social isolation, and poor mental wellbeing. No estimates of stigma prevalence were identified.

INTERPRETATION

Existing evidence shows that women with GDM report stigma, which may affect both their mental and physical health. Further investigations into the prevalence of stigma and long-term consequences of stigma are much needed.

FUNDING

The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

The burden and risks of emerging complications of diabetes mellitus

The traditional complications of diabetes mellitus are well known and continue to pose a considerable burden on millions of people living with diabetes mellitus. However, advances in the management of diabetes mellitus and, consequently, longer life expectancies, have resulted in the emergence of evidence of the existence of a different set of lesser-acknowledged diabetes mellitus complications. With declining mortality from vascular disease, which once accounted for more than 50% of deaths amongst people with diabetes mellitus, cancer and dementia now comprise the leading causes of death in people with diabetes mellitus in some countries or regions. Additionally, studies have demonstrated notable links between diabetes mellitus and a broad range of comorbidities, including cognitive decline, functional disability, affective disorders, obstructive sleep apnoea and liver disease, and have refined our understanding of the association between diabetes mellitus and infection. However, no published review currently synthesizes this evidence to provide an in-depth discussion of the burden and risks of these emerging complications. This Review summarizes information from systematic reviews and major cohort studies regarding emerging complications of type 1 and type 2 diabetes mellitus to identify and quantify associations, highlight gaps and discrepancies in the evidence, and consider implications for the future management of diabetes mellitus.

Stigma evaluation for diabetes and other chronic non-communicable disease patients: Development, validation and clinical use of stigma scale - The Kanden Institute Stigma Scale

AIMS/INTRODUCTION

The aim of this study was to develop a scale to evaluate disease stigma in patients with lifestyle-related chronic non-communicable diseases (LCNCDs), which we named the Kanden Institute Stigma Scale (KISS), and to consider its possible clinical application for patients with diabetes.

MATERIALS AND METHODS

An initial 90 questions were drafted and categorized into six subscales according to the manifestations of stigma. The final version of the KISS was developed as a 24-item questionnaire comprising four items for each subscale.

RESULTS

A total of 539 outpatients including 452 patients with diabetes and 87 patients without diabetes were recruited. Construct validity was confirmed by assessing the correlation with previously established measures. Confirmatory factor analysis showed the KISS to have good model fitness (adjusted goodness-of-fit index = 0.856). Test-retest reproducibility analysis showed that the intraclass coefficient of the first and a second KISS was 0.843 (P < 0.001), indicating excellent reproducibility. The KISS showed higher scores for patients with diabetes than for patients without diabetes (12.23 ± 0.49 vs 5.76 ± 0.73, P < 0.05). The KISS score was significantly higher in type 1 and type 2 diabetes patients taking insulin therapy than in type 2 diabetes patients not taking insulin (P < 0.05).

CONCLUSION

The KISS is a validated and reliable questionnaire for assessment of stigma among patients with diabetes as well as other lifestyle-related chronic non-communicable diseases, and might contribute to identifying and rectifying diabetes stigma, as well promoting awareness among health care professionals of this very consequential health problem.

A survey of clinical physician's perceptions of stigma and advocacy in patients with type 2 diabetes in Kanagawa, Japan

AIMS/INTRODUCTION

To investigate the recognition status of stigma/advocacy in patients with type 2 diabetes in clinical practice settings.

METHOD

A questionnaire survey on stigma/advocacy of patients with diabetes was carried out for members of the Kanagawa Physicians Association in July 2021.

RESULTS

The respondents consisted of 33 (16.6%) physicians specializing in diabetes (the D group) and 166 (83.4%) non-specialists (the ND group). 100% of the D group and 48.8% of the ND group knew that patients may be prejudiced or discriminated against because of diabetes. In the question of whether they know the terms 'stigma' and 'advocacy', 'know' was 97.0% and 94.0% in the D group, compared with 45.8% and 36.7% in the ND group, respectively. 97.0% of the D group and 19.9% of the ND group know the advocacy activities of the Japanese Diabetes Society (JDS) and the Japan Association for Diabetes Education (JADEC). The specific contents of the stigma were often unknown or never experienced in the ND group. A free description of the strategy for reducing or eliminating stigma was analyzed by text mining. 'Giving consideration to the patients' feelings', 'Commitment to the problem', and 'Dialogue' were frequent, and there was no significant difference between the two groups.

CONCLUSIONS

The clinician's understanding of stigma/advocacy associated with having diabetes was insufficient, and activities that alert clinicians to stigma/advocacy, especially those in the ND group, was a theme to be addressed. More awareness-raising activities for stigma/advocacy will lead to better treatment and a better quality of life for patients with diabetes.