Examination of the Relationship Between Diabetes Knowledge and Self-Stigma Levels in Individuals with Type 2 Diabetes

Technical Summary: Examination of the Relationship Between Diabetes Knowledge and Self-Stigma Levels in Individuals with Type 2 Diabetes

Problem Statement
Type 2 Diabetes Mellitus (T2DM) is a chronic condition where associated stigma can significantly impair psychosocial well-being, self-perception, and disease self-management. While existing literature establishes that stigma negatively affects self-esteem, self-efficacy, and treatment adherence, the specific relationship between a patient's level of diabetes knowledge and their internalized self-stigma remains underexplored. Current research lacks sufficient elucidation of the dynamics between these two variables, creating a gap in understanding how educational interventions might interact with psychosocial adaptation processes. This study aims to address this gap by examining the relationship between diabetes knowledge and self-stigma levels in adults with T2DM.

Methodology

• Design and Setting: A prospective, descriptive, cross-sectional study conducted between March 18, 2025, and November 18, 2025, at a hospital in Izmir, Turkey.
• Participants: The sample consisted of 256 adults (aged 18+) diagnosed with T2DM for at least one year and currently using insulin therapy. Exclusion criteria included a history of diabetic foot amputation, diabetic nephropathy, diabetic retinopathy, communication difficulties, or psychiatric disorders.
• Data Collection Instruments:
  1. Socio-demographic Information Form: 23 questions covering demographics and diabetes-related history.
  2. Self-Stigma Scale (SSS): A Turkish adaptation of the 39-item scale by Mak and Cheung (2010). In this study, three items were removed, resulting in a 36-item scale (0–108 score range) with three subscales: cognitive, affective, and behavioral. The scale demonstrated high internal consistency (Cronbach's $\alpha$ = 0.971).
  3. Turkish Version of the Michigan Revised Diabetes Knowledge Test (Tr-DKT2): A 23-item test assessing general diabetes knowledge and insulin use.
• Statistical Analysis: Data were analyzed using SPSS. Normality was assessed via the Kolmogorov–Smirnov test. Group differences were evaluated using Independent Samples t-tests, Mann–Whitney U tests, One-Way ANOVA, and Kruskal–Wallis tests. Correlations were examined using Spearman's rho. A multiple linear regression analysis was performed with the Self-Stigma Scale total score as the dependent variable and specific predictors (history of hypoglycemic/hyperglycemic coma, difficulty accepting the disease, and difficulty coping with the disease) to determine variance explanation.

Key Results

• Descriptive Statistics: The mean age of participants was 56.06 years (67.2% female). The mean Self-Stigma Scale score was 48.37 ± 23.85. The mean Diabetes Knowledge Test score was 10.42 ± 3.92, indicating a relatively low level of disease knowledge.
• Demographic Correlates:
  • Education and Marital Status: University graduates and single participants demonstrated significantly higher diabetes knowledge scores compared to other educational groups and married participants ($p < .001$).
  • Employment: Significant differences were found in both self-stigma and knowledge scores based on employment status.
  • Smoking: Smokers exhibited significantly lower self-stigma levels compared to non-smokers ($p = .002$).
• Clinical and Psychosocial Correlates:
  • Glycemic History: Participants with a history of hyperglycemia had significantly higher self-stigma and higher knowledge scores. Conversely, those with a history of hypoglycemia exhibited significantly higher self-stigma levels ($p < .001$).
  • Perception of Disease: Participants who agreed that diabetes is "difficult to accept" or "difficult to cope with" had significantly higher self-stigma scores ($p < .001$).
  • Education: Participants who received diabetes education had significantly higher knowledge scores ($p = .001$).
• Correlation Analysis:
  • A weak, non-significant correlation was found between the total Self-Stigma Scale score and the Diabetes Knowledge Test score ($r = -0.050$ to $0.078$, $p > .05$).
  • Strong positive correlations were observed between the total Self-Stigma Scale and its subscales ($r = .856$–$.979$), confirming the scale's structural integrity.
• Regression Analysis:
  • A multiple linear regression model including hypoglycemic coma, difficulty accepting the disease, and difficulty coping with the disease was statistically significant ($F = 18.935$, $p < .001$).
  • The model explained 23.3% of the variance in self-stigma scores ($R^2 = 0.233$).
  • Predictors: Difficulty coping with the disease ($\beta = 0.248$), difficulty accepting the disease ($\beta = 0.214$), and a history of hypoglycemic coma ($\beta = 0.129$) were significant positive predictors of self-stigma. Diabetes knowledge was not a significant predictor in this model.

Key Contributions

1. Clarification of Variable Relationships: The study provides empirical evidence that diabetes knowledge levels are not directly associated with self-stigma levels in T2DM patients, challenging the assumption that increased knowledge alone mitigates internalized stigma.
2. Identification of Stronger Predictors: Through multivariate analysis, the research identifies psychosocial factors (difficulty in acceptance and coping) and specific clinical events (hypoglycemic coma) as stronger determinants of self-stigma than biomedical knowledge.
3. Validation of Measurement: The study confirms the reliability of the Turkish adaptation of the Self-Stigma Scale in a T2DM population, with high Cronbach's alpha coefficients across total and subscale scores.

Significance and Implications
The authors claim that these findings highlight the necessity of shifting the focus in diabetes care from purely educational interventions to a more holistic approach that addresses psychological adaptation.

• Clinical Practice: Nurses and healthcare providers should assess not only a patient's knowledge of diabetes but also their psychosocial adjustment, specifically their ability to accept and cope with the disease.
• Intervention Strategy: Identifying difficulties in acceptance and coping can guide individualized nursing interventions. The study suggests that counseling and psychoeducational programs aimed at improving coping strategies and acceptance may be more effective in reducing self-stigma than knowledge transfer alone.
• Future Research: The authors note that the cross-sectional design limits causal inference and call for future longitudinal studies incorporating additional psychosocial variables such as depression, anxiety, and social support to further understand the factors influencing self-stigma.