Diabetes‐Related Stigma, Hemoglobin A1c, and Psychological and Behavioral Outcomes Among Adults With Type 2 Diabetes in Ghana: A Structural Equation Modeling Approach

ABSTRACT

Introduction
Whereas diabetes‐related stigma is increasingly recognized as a barrier to diabetes management, little is known about this social phenomenon in collectivist African settings. The purpose of this study was to examine diabetes‐related stigma among adults with type 2 diabetes (T2D) in Ghana, highlighting behavioral and psychological mechanisms underpinning the impact of stigma on hemoglobin A1C.


Design
Cross‐sectional analytical design.


Methods

Adults with T2D (
n
 = 190), seeking care at a tertiary hospital in Ghana, were recruited. A battery of questionnaires assessing psychological (diabetes‐related stigma, depression, anxiety, diabetes distress) and behavioral constructs (diabetes concealment and diabetes self‐management) were administered. Venous blood samples were obtained for A1C assessment. A latent variable, “adverse psychological outcomes” comprising anxiety, depression, and diabetes distress, was derived and validated using confirmatory factor analysis. Structural equation modeling was used to test multiple psychological and behavioral pathways through which stigma was associated with A1C.



Results

Participants had an average age of 59.44 (SD = 10.7) years, were mostly female (70.5%,
n
 = 134), and had T2D diagnosis for a median of 14.5 years. We found significant indirect effects of T2D stigma on HbA1c through adverse psychological outcomes alone (
β
 = 0.16; 95% CI: 0.01, 0.32,
p
 = 0.038), as well as the combination of adverse psychological outcomes and self‐management behaviors (
β
 = 0.16; 95% CI: 0.001 to 0.32,
p
 = 0.048). We also found that the association between T2D stigma and diabetes self‐management was fully mediated by adverse psychological outcomes, and participants who conceal their diabetes tend to report greater adverse psychological outcomes.



Conclusion
We note that adverse psychological outcomes play a central role in how T2D stigma is associated with HbA1c. Our findings provide preliminary insight into potential aspects of diabetes that may be targeted in future stigma‐reduction interventions.


Clinical Relevance
Our results do provide some indication that addressing mental health issues in individuals with T2D may be an effective intervention strategy in curtailing the adverse clinical effects of T2D stigma. Additionally, our results highlight the importance of incorporating mental health care as part of routine diabetes management in Ghana and other similar African countries where mental health issues are often not prioritized by the healthcare system.