Kato et al. stated that self-stigma is to the biased attitude in which individuals develop negative attitudes toward themselves because of their various conditions. This condition can be referred to as internalized stigma. Contrast with social-stigma, self-stigma may particularly affect to individual belief and behaviors toward disease self-management in patients with chronic disease. The literatures have reported that the self-stigma under chronic diseases conditions would be associated with a poor attitude toward self-care behaviors, and its results may negatively impacts on their health outcome such as quality of life. Recently, the importance of self-stigma was emphasized in mental health and AID study, and comprehensive review study was also published in prior.
However, self-stigma in patients with chronic disease such as diabetes has not yet been investigated. Thus, the purpose of this study was to comprehensively review the concept of self-stigma in patients with chronic disease, and to synthesize the attributes of self-stigma using published literatures. Based on the findings from this meta-synthesis, the concept of self-stigma in chronic disease conditions can be distinguished from mental health, and classified the attributes of self-stigma for patients with chronic disease. Ultimately, the instrument for measuring the self-stigma under chronic disease condition can be developed in future study.
A systematic literature search was conducted using electronic databases such as Pubmed, Cochrane and CINAHL from 1986 to 2016 years. Mesh terms such as ‘self’ or ‘internalized’ and ‘stigma’ were used. The inclusion criteria were as follows; a) English literatures, b) human study, c) original studies using qualitative/quantitative methods, and d) sample with chronic diseases condition such as cancer, diabetes, hypertension etc. The exclusion criteria were sample with a) mental health problem, b) HIV/AIDS, c) non-chronic condition such as smoking, and d) concept was not clearly presented in studies. Two researchers were searched and coded using coding scheme independently. If there was found the discrepancies between reviewers, principal investigator was resolved. Coding scheme consist of study characteristics (sample size, clinical condition of participants, study design etc.) and the definition or attributes of self-stigma.
Total 878 studies were initially searched using three electronic databases. Among them, 237 duplicated studies were removed, and the remained 641 were reviewed its abstracts. However, 491 studies did not meet the inclusion criteria. In the next step, 150 studies were reviewed the full-text by researchers, but 117 studies were excluded due to have not the concept of self-stigma. Finally, 33 literatures were analyzed in meta-synthesis.
The final 33 studies included 12,831 samples with chronic diseases such as diabetes mellitus, hepatitis C, liver cirrhosis, stutter, epilepsy, leprosy, TB, ESRD, neuromuscular disease, lung cancer, and overweight/obesity. Research methods of twenty-seven studies were quantitative research, and remained six were qualitative research.
The attributes of the self-stigma in chronic disease were divided into two categories: interpersonal focused self-stigma and self-blamed focused self-stigma in this meta-synthesis. The attributes of interpersonal focused self-stigma included stereotype agreement, withdrawal from social relationships, and fear of disclosure of the illness. It would include avoiding the social relationships with people due to fear of discrimination or disadvantage because of their disease. This behavior was related to the social stereotypes that some of the chronic disease was considered to be a lifestyle-related. This phenomenon was appeared in patients who have more focused on interpersonal relationship. They were even disconnecting from social networks because they have worrisome about their illness that would affect social activities. On the other hand, self-blamed focused self-stigma might be associated with negative thoughts or feelings about themselves. It included self-blame, guilt/shame, lower sense of self-worth, feeling unhealthy, and anxiety or low expectations of the future. Those attributes were related to prejudices about one self. The patients who have self-blamed or feeling guilty, and show reduced confidence in self-care management tend to be thought that the cause of their illness is their own mistakes.
The finding showed that the attributes of self-stigma stigma in patients with chronic disease were different from mental health and other conditions. The attributes of self-stigma from this meta-synthesis were divided into two folds such as interpersonal focused self-stigma and self-blamed focused self-stigma. However, those attributes were affected by patients’ situations. Based on this meta-synthesis, self-stigma in patients with chronic disease can be understood and classified, but little information was remained on how to measure the self-stigma. Therefore, it should be needed to investigate the systematic review again for self-stigma measurement tool in further study.