A recent BMC Public Health Study explores the moderating role of empowerment and the mediating role of stigma in the association between quality of life (QoL) and psychological resilience (PR) among diabetic patients in China. 

Study: The relationship between psychological resilience and quality of life among the Chinese diabetes patients: the mediating role of stigma and the moderating role of empowerment. Image Credit: Krakenimages.com / Shutterstock.com

Background

The prevalence of diabetes mellitus (DM) has increased over the past several years as a result of various lifestyle changes. DM patients are vulnerable to other health problems, such as cardiovascular diseases (CVD) and diabetic foot. Depression and anxiety are also common among diabetic patients, thus leading to poor QoL in this patient population.

QoL encompasses how individuals view their social, psychological, and physical well-being. Research has shown that QoL is lower among DM patients than those without DM, thus indicating the importance of maintaining QoL in DM patients.

PR could affect QoL, with stigma potentially having a mediating role in this association. Stigma implies negative emotional experiences that arise from being discriminated against due to having a particular disease. DM carries a stigma, as it is often thought to result from poor eating habits. 

The direct and indirect effects of PR on QoL can also be affected by empowerment, by which patients acquire more self-awareness. This knowledge could be used to change their and other people's attitudes towards a disease, thereby raising QoL. Empowerment is particularly important, as most DM patients report low PR due to insufficient knowledge about the disease itself and treatment methods. 

About the study

A moderated mediation model was developed to assess further the association between QoL, PR, stigma, and empowerment. The first hypothesis was to understand the mediating role of stigma between QoL and PR, while the second study goal was to study whether empowerment moderated the relationship between QoL, stigma, and PR. 

The random number table and multi-stage stratified sampling methods were used to collect data between June and September 2022. In Wuhu, six tertiary hospitals were first numbered, with the First Affiliated Hospital of Wannan Medical College chosen using the random number method. The endocrinology and geriatric departments were randomly selected from this hospital.

The next step was randomly selecting type 2 DM (T2DM) patients and interviewing them at survey points. The Connor-Davidson Elasticity Scale (CD-RISC) was used to measure the PR of patients, whereas the Stigma Scale for Chronic Illness (SSCI) was used to assess stigma, and the Diabetes Empowerment Scale (DES) provided data on empowerment. To measure the QoL, the Diabetes Quality of Life Scale (DQoL) was used.

Key findings

PR significantly affected stigma at high levels of empowerment among DM patients. Furthermore, QoL was significantly impacted by stigma at high or low levels of empowerment.

Even after controlling for confounding factors, high PR levels were associated with improved QoL. The PR scores observed among diabetic patients were much lower than the normal population, as documented by other studies.

Stigma mediated the association between QoL and PR. Good PR following disease diagnosis implies less stigma experience, lower negative impact, and higher QoL.

Comparatively, lower PR could indicate that individuals will get more anxious, thereby raising stigma and lowering QoL. Therefore, for effective DM management, attention should be paid to the indirect impact of PR on QoL through stigma, in addition to the direct effect of PR on QoL.

Empowerment significantly moderated part of the path through which PR affected QoL through stigma. For high-empowered DM patients, the effect of PR on stigma was much higher. Better knowledge of the disease leads to better physical and mental health management, lowering stigma's adverse effects. 

Conclusions

A key limitation of the current study is the inability to make causal inferences about the observed correlations due to the cross-sectional nature of the analysis; however, this could be improved in future longitudinal studies. The self-reported nature of the study also makes the data highly subjective and susceptible to bias. 

The present study provided important insights into the association between QoL and PR using a moderated mediator model. A significant negative relationship was observed between PR and QoL, and stigma mediated part of this relationship.

In patients with high levels of empowerment, PR had a much stronger effect on stigma. Simultaneously, in low-empowered patients, the effect of stigma on QoL was much more substantial.