Stigma, self-efficacy, and adherence behaviors in people with type 2 diabetes: unexpected outcomes

Abstract

Type 2 diabetes mellitus is a health condition treated with behavioral modifications including changes in diet, exercise, foot care regimens, and medication. Stigma associated with type 2 diabetes negatively effects health outcomes, whereas patient-provider relationships positively affects health outcomes. The growing literature base on type 2 diabetes stigma and health outcomes is mostly conducted outside of the United States. The present study used online crowdsourcing methods to gather cross-sectional survey data from people (n=152) who have been diagnosed with type 2 diabetes and are living in the United States. Participants completed the survey battery measuring stigma, self-efficacy, patientprovider relationships, and health behaviors. It was predicted that 1) internalized stigma would have a negative impact on self-care behaviors including diet, exercise, foot care, and medication adherence as well as glycated hemoglobin [HbA1C] levels 2) self-efficacy would mediate each of those relationships, and 3) the patient-provider relationship, characterized by trust in providers would moderate the relationship between stigma and self-efficacy thus indirectly moderating self-care behaviors and HbA1C. To test these hypotheses, a set of five moderated-mediation analysis were conducted to test each outcome variable of diet, exercise, foot care, medication adherence, and HbA1C. Main findings of this study revealed paradoxical relationships between stigma, self efficacy, and trust in providers, although consistent with psychological reactance theory. Stigma was associated with medication non-adherence and worse HbA1C, which is consistent with literature. Results of this study suggest that patients who exhibit psychological reactance may struggle to adhere to recommendations despite being more likely to report that everything is okay. This dynamic may make it difficult for providers to accurately gauge patient engagement in care, ability, or progress in health behavior change. However, one could argue responding to stigma with reactance may be protective in other ways. There was some evidence to suggest providers can attend to reactance by attuning to trust within the patient-provider relationship. In summary, this study adds to the pool of literature on stigma and type 2 diabetes, specifically within the US which is important considering variances in social climates and health care systems across nations. Future research should corroborate our suppositions about the relationships between stigma, self-efficacy, and psychological reactance.