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Original research
How self-stigma affects patient activation in persons with type 2 diabetes: a cross-sectional study
  1. Asuka Kato1,
  2. Yuko Fujimaki2,
  3. Shin Fujimori2,
  4. Akihiro Isogawa3,
  5. Yukiko Onishi4,
  6. Ryo Suzuki5,
  7. Kohjiro Ueki5,
  8. Toshimasa Yamauchi5,
  9. Takashi Kadowaki5,
  10. Hideki Hashimoto1
  1. 1Department of Health and Social Behavior, School of Public Health, The University of Tokyo, Tokyo, Japan
  2. 2Department of Internal Medicine, School of Medicine, Teikyo University, Tokyo, Japan
  3. 3Diabetes Care Division, Mitsui Memorial Hospital, Tokyo, Japan
  4. 4Division of Diabetes and Metabolism, The Institute for Adult Diseases, Asahi Life Foundation, Tokyo, Japan
  5. 5Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
  1. Correspondence to Dr Asuka Kato; asukakato-tky{at}


Objectives Self-stigma is associated with lower patient activation levels for self-care in persons with type 2 diabetes mellitus (T2DM). However, the causal pathway linking self-stigma with patient activation for self-care has not been shown. In order to determine how self-stigma affects patient activation for self-care, we tested a two-path hypothetical model both directly and as mediated by self-esteem and self-efficacy.

Design A cross-sectional study.

Setting Two university hospitals, one general hospital and one clinic in Japan.

Participants T2DM outpatients receiving treatment (n=209) completed a self-administered questionnaire comprising the Self-Stigma Scale, Patient Activation Measure, Rosenberg Self-Esteem Scale, General Self-Efficacy Scale, Patient Health Questionnaire, haemoglobin A1c test, age, sex and body mass index.

Primary and secondary outcome measures Self-stigma levels were measured by using the Self-Stigma Scale. Patient activation levels were measured by the Patient Activation Measure.

Results Path analysis showed a strong relationship between self-stigma and patient activation (χ2=27.55, p=0.120; goodness-of-fit index=0.97; adjusted goodness-of-fit index=0.94; comparative fit index=0.98; root mean square error of approximation=0.04). Self-stigma had a direct effect on patient activation (β=−0.20; p=0.002). Indirectly, self-stigma affected patient activation along two paths (β=0.31; p<0.001) by reducing self-esteem (β=−0.22; p<0.001) and self-efficacy (β=−0.36; p<0.001).

Conclusions Due to the cross-sectional design of the study, longitudinal changes between all the variables cannot be established. However, the findings indicate that self-stigma affected patient activation for self-care, both directly and as mediated by self-esteem and self-efficacy. Interventions that increase self-esteem and self-efficacy may decrease self-stigma in patients with T2DM, thus increasing patient activation for self-care.

  • diabetes & endocrinology
  • type 2 diabetes
  • psychosocial research
  • patient education
  • stigma
  • patient activation

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  • Contributors AK conceptualised and designed the study. AK coordinated the study acquired, analysed, interpreted the data and prepared the paper. HH helped to analyse and interpret the data. AK and HH held primary responsibility for data access. YF, SF, AI, YO, RS, KU, TY and TK made significant contributions to the critical interpretation of the results in terms of important practical content. All authors read and approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Research Ethics Committee of the University of Tokyo Graduate School of Medicine and Faculty of Medicine and was approved and supported by the participating facilities (Approval No. 3269).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Extra data can be accessed via the Dryad data repository at with the

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