Perceived Stigma Among People With Chronic Health Conditions

Abstract

Objectives:

This study addresses whether age, functional limitation and other stressor exposure, and psychosocial coping resources influence variation in perceived stigma and the form this influence takes (i.e., independent and/or interdependent).

Methods:

Using data from two waves of a large community study of adults (age 20–93) with chronic health conditions (n = 417), a residual change regression analysis considers direct and moderating factors influencing perceived stigma over a 3-year period.

Results:

Age, functional limitation, the experience of discrimination, and self-esteem independently account for variation in perceived stigma. Moderation tests reveal that age is associated with a greater increase in stigma in the context of greater functional limitation and increases in limitation. Functional limitation and stressor exposure are also associated with declines in stigma in the context of greater mastery and self-esteem.

Discussion:

Multiple processes bear on perceived stigma among people with chronic health conditions. Implications for stigma and stress research are discussed.

Keywords

age functional limitation stigma stressor exposure

Introduction

Perceived stigma—defined as an awareness of social devaluation or discrimination based on a socially stigmatizing attribute (Corrigan & Watson, 2002; Corrigan, Watson, & Barr, 2006)—is associated with a wide range of negative consequences among people with chronic physical health conditions, including smaller social networks, marital and other relationship problems, employment difficulties, lower quality of life, and greater functional impairment (Crocker, Major, & Steele, 1998; Miller & Major, 2000; Van Brakel, 2006).

It was once assumed that all people with chronic health conditions must experience perceived stigma to some degree and its deleterious effects as a result (Braddock & Parish, 2003; Goffman, 1963; Joachim & Acorn, 2000). However, there is now a growing recognition that people with chronic health complaints vary both in terms of whether and the extent to which they experience characteristics of perceived stigma associated with physical health, such as an awareness of public scrutiny and avoidance by others, as well as being made to feel ashamed, embarrassed, or blamed for their condition (Cahill & Eggleston, 1995; Earnshaw & Quinn, 2012; Kilinc & Campbell, 2009). This has directed attention to the question of what risk factors account for variation in perceived stigma among people with chronic health conditions (Charmaz, 2000; Hamilton-West & Quine, 2009; Quinn & Chaudoir, 2009). Recent study demonstrates that stressor exposure and the availability of psychosocial coping resources are important antecedents of perceived stigma (Crocker et al., 1998; Earnshaw & Quinn, 2012; Hamilton-West & Quine, 2009; Joachim & Acorn, 2000; O’Brien & Major, 2005).

However, important limitations of this work are the tendency to discuss the effects of only one potential source of perceived stigma (e.g., low social support), at one point in time, and for a specific health condition (e.g., epilepsy or multiple sclerosis). As a consequence, the relative contributions of various factors that likely underlie perceived stigma are not well understood, and it is uncertain whether these factors influence changes in perceived stigma over time. It is also unclear from prior work specifically how stressor exposure and coping resources influence perceived stigma. For example, these factors may independently influence perceived stigma and/or have interdependent effects. In addition, the focus on specific health conditions—particularly those that carry the greatest stigma potential—has prevented the ability to develop a more general understanding of perceived stigma associated with physical health (Susman, 1994; Van Brakel, 2006). Notably, perceived stigma associated with the types of chronic health conditions older adults are most likely to experience, such as heart disease, arthritis, diabetes, or high blood pressure (Verbrugge & Patrick, 1995), has received little attention.

Indeed, previous research on stigma and physical health has generally not acknowledged a major demographic shift of the 20th century that has profoundly altered the composition of the population of people with chronic health complaints. The aging of the population has been accompanied by a sizable increase in the number of older adults who experience chronic health conditions (Brault, 2008), which means that the population of people with such conditions is now both larger and older than in the past (Brault, 2008). Among those over the age of 65, for instance, the U.S. Census now estimates that more than half (52%) experience some form of physical limitation and 37% experience severe limitations (Steinmetz, 2006). As a consequence of this demographic shift, age differences in perceptions of stigmatization may also be anticipated.

Motivated by these observations, the present study draws on the stress and coping literature (Pearlin, 1989; Pearlin, Menaghan, Lieberman, & Mullan, 1981) to further explore variation in perceived stigma among adults (age 20–93) with a range of chronic health conditions (reported in Appendix). The relative significance of age, stressor exposure, and psychosocial coping resources for variation in perceived stigma over a 3-year period is considered using a novel measure of perceived stigma that was developed to be relevant across a range chronic health conditions. The possibility that age, stressors, and coping resources may have synergistic effects is also explored.

A Stress Process Perspective

Stress process models posit that social statuses, such as age, influence adverse outcomes in their own right and that their effects can also be exacerbated by stressor exposure and offset by the availability of psychosocial coping resources (Pearlin, 1989). Applications of the stress process perspective further demonstrate that the impact of high stressor exposure tends to be less when one has robust coping resources and that the benefit of coping resources can be diminished in the context of high stressor exposure (Turner & Brown, 2010). Although a stress process perspective is used most typically for understanding social status variation in mental and physical health markers, such a perspective may also be useful for understanding the antecedents of perceived stigma.

Thus, the first goal of this study is to assess whether perceived stigma varies fundamentally by age. Although little attention has been paid to the potential for social status variation in the experience of stigma among people with chronic health conditions, statuses such as age are recognized as socially significant because they confer power and access to resources (Link & Phelan, 2001). As such, people who occupy certain social statuses may be better poised to address challenges associated with physical limitations and, thus, perceive themselves to be less stigmatized (Dyck, 1995; Kelley-Moore, Schumacher, Kahana, & Kahana, 2006). Some evidence indicates, for example, that the experience of poor physical health may be accompanied by fewer feelings of stigmatization among older adults because it is more normative in later life (Borawski, Kinney, & Kahana, 1996; Erler & Garstecki, 2002). Older people with chronic health conditions also appear to be more likely to receive positive affirmations than younger people with chronic health conditions (Menec & Perry, 1995). Alternately, because age and chronic health conditions both represent sources of stigma, older people with chronic health conditions may feel greater stigmatization.

Variation in perceived stigma among persons with chronic health conditions may also derive from variation in stressor exposure and psychosocial coping resources. In assessing the effects of stressor exposure, the impact of both individual stressors and stressors that are socially based is investigated. Individual stressors include the occurrence of potentially traumatic life events (i.e., major and recent life events) and chronic strains, whereas social stressors refer to adverse experiences in the social environment, such as discrimination (Meyer, 2003). Both forms of stressor exposure are thought to have adverse consequences because they cause changes in one’s life circumstances and require adaptation (Brown & Turner, 2012; Pearlin, 1989). However, secondary stressors are hypothesized to be particularly relevant in the extent to which they are stigma relevant (Major & O’Brien, 2005; Miller & Major, 2000). This is because, for some, an awareness of discrimination or the potential for future discriminatory encounters can be a defining feature of how persons with disabilities experience social life (Mona, Cameron, & Crawford, 2004; Olkin, 2002).

Here, and consistent with prior stress research, the level of functional limitation is considered as a chronic stressor because it often involves ongoing challenges in directing and regulating social roles and activities (Brown & Turner, 2010; Turner & Noh, 1988). Because previous research demonstrates that greater functional limitation or increase in limitation, compared to other forms of stressor exposure, is one of the strongest risk factors for depression and other negative health outcomes (Brown & Turner, 2010; Jeon & Dunkle, 2009), it is also hypothesized to be a robust predictor of perceived stigma.

Prior research also provides grounds for anticipating that the coping resources of social support, mastery and self-esteem may directly influence perceived stigma. Social support refers to one’s level of certainty that he or she is loved, valued, and cared for by significant others (Cobb, 1976; Turner & Brown, 2010). Mastery refers to a sense of personal control (Pearlin & Schooler, 1978), whereas self-esteem refers to a positive sense of self-worth (Rosenberg, 1979). Prior research indicates, for example, that people with physical health conditions feel more stigmatized when they view themselves as socially incompetent or unable to control their social relationships (Charmaz, 2000; Crocker & Quinn, 2000). Self-esteem and mastery are also importantly linked with perceived stigma among people with health conditions in the extent to which one’s health condition poses a threat to the self-concept (Quinn & Chaudoir, 2009) and one is able to control his or her symptoms (Jacoby, 1994).

The availability of these coping resources and stressor exposure may additionally help clarify our understanding of the impact of age on perceived stigma. In general, research findings concerning the role of stressor exposure in attenuating the effects of age are inconsistent. In research focusing on individual-level stressors, for example, some evidence suggests that stress-related increases in negative affect are more pronounced among older adults compared with their younger counterparts (Mroczek & Almeida, 2004), while other evidence suggests a greater effect for younger adults (Uchino, Berg, Smith, Pearce, & Skinner, 2006) or no age differences (Stawski, Sliwinski, Almeida, & Smyth, 2008). However, research concerning the moderating effects of age and functional limitation for mental health outcomes consistently demonstrates that the effects of functional limitation are less with advancing age (Mirowsky & Ross, 1992; Turner & Noh, 1988), suggesting a similar possibility with respect to perceived stigma. Further, evidence that social support, mastery and self-esteem decline with age (Marcum, 2013; Robins, Trzesniewski, Tracy, Gosling, & Potter, 2002; Schieman, 2001) suggests that the benefits of these coping resources may vary systematically by age.

There is additional evidence that coping resources may offset the effects of level of functional limitation and other stressors among people with chronic health conditions. Several scholars, for instance, describe how strong social relationships and positive self-evaluations can supplant the negative effects of even severe functional restraints (Cahill & Eggleston, 1995; Joachim & Acorn, 2000; Lock & Scheper-Hughes, 1996) and help to counteract discriminatory experiences among people with chronic health conditions (Charmaz, 2000; Joachim & Acorn, 2000).Although it is less clear whether these coping resources might counterbalance the effects of other stressors, taken together, this research indicates that these resources may attenuate the effects of stress exposure in the prediction of perceived stigma.

In summary, previous research supports the need for further study of the independent and interdependent influences that age, stressor exposure, and psychosocial resources may have on perceptions of stigma among people with chronic health conditions. The present study examines the extent to which variation in perceived stigma associated with chronic health conditions is influenced by these factors over a 3-year period. Additionally, because these factors are linked with depression among people with chronic health conditions (Brown & Turner, 2010; Turner & Noh, 1988; Yang, 2006), the possibility that their effect on perceived stigma is an artifact of their association with the occurrence of major depressive disorder is investigated.

Method

Study Procedures and Sample

Data are derived from a two-wave panel study of Miami-Dade County, Florida, residents that was undertaken in order to examine the social determinants of mental health problems among individuals with and without chronic health conditions. Based on national age, gender, and race/ethnicity-specific rates of disability, and on the Miami-Dade County demographic structure, approximately 10,000 households were randomly screened to develop a sampling frame within which people with chronic health conditions were significantly overrepresented (Turner, Lloyd, & Taylor, 2006). Stratified random samples were drawn, so that women and men were equally represented within the study and that the racial/ethnic composition of study participants would reflect that of the Miami-Dade County community. Additional details regarding the sampling procedure are presented by Turner, Lloyd, and Taylor (2006).

From 2000 to 2001, a total of 1,986 first-wave interviews were completed, with a success rate of 82%. Interviews were administered by well-trained and predominantly bilingual interviewers using computerized questionnaires in either English or Spanish, as preferred by each participant. The Spanish version of the questionnaire was developed in a four-step process: translation by a professional translator, review and revision of the translation by bilingual psychologists and sociologists knowledgeable about the constructs being assessed, revision based on the results of a back translation, and focus group work with bilingual individuals of diverse background to ensure comparable meaning of the Spanish version across persons of differing national origins.

The study included 900 people who were initially screened as having a chronic health condition, of whom 559 confirmed this status within the first interview. Respondents were reinterviewed 3 years later. Excluding the 100 Wave 1 (W1) participants who died in the interim and 59 W1 participants who were too ill to be interviewed, the second wave of interviews achieved a success rate of 82.5%. The working sample for this study includes the 417 respondents who confirmed that they experience a chronic health condition and provided complete responses during both interviews.

It should be noted that, because this is a sample of people with chronic health conditions, it includes a greater proportion of older respondents than what is observed in the general population. Age in the sample ranges from 20 to 93, with a median of 59 whereas, in contrast, the median age of the general population of Miami-Dade County in 2000 was 35.6. Given this discrepancy in age, it is inaccurate to suggest that this sample is representative of the Miami-Dade County population. However, the sample is generally representative of people with chronic health conditions in Miami-Dade County.

Measures

Summary statistics for all study variables are found in Table 1. The outcome variable, perceived stigma, is assessed at Wave 2 (W2). W1 levels of perceived stigma are controlled in the regression analyses in order to assess changes in stigma across the two waves of data.

Table 1.

Means and Standard Deviations of Variables.

Characteristics	Range	M	SD
Perceived stigma
W1	0–35	10.710	5.181
W2	0–35	10.949	5.254
Age (W1)	20–93	59.787	15.191
Functional limitation
W1	5–80	36.503	14.568
W2	7–79	33.122	13.723
Δ Functional limitation	–35–46	2.669	11.505
Major life events
W1	2–25	10.741	4.192
Recent life events
W1	0–8	.917	1.430
W2	0–7	.580	1.243
Δ Recent life events	–6–7	–.405	1.796
Major discrimination
W1	0–6	1.185	.722
W2	0–7	1.557	1.119
Δ Major discrimination	–5–5	1.269	1.417
Day-to-day discrimination
W1	0–40	4.423	6.351
W2	0–32	5.714	5.720
Δ Day-to-day discrimination	–29–19	–9.057	7.322
Chronic strains***
W1	0–40	6.363	7.782
W2	0–53	5.505	7.034
Δ Chronic strains	–34–43	1.676	8.571
Social support**
W1	0–64	53.745	11.227
W2	0–64	38.318	10.692
Δ Social support	–53–33	–16.033	11.975
Mastery
W1	7–35	23.765	6.546
W2	8–33	22.132	6.183
Δ Mastery	–26–23	–1.961	7.450
Self-esteem
W1	6–30	27.161	3.643
W2	6–30	24.275	3.791
Δ Self-esteem	–20–13	–3.071	4.514
Sociodemographic variables
Sex (% female)	0,1	56.5	—
Socioeconomic status (W1)	–2.359–2.702	–.287	.946
Race/ethnicity (%)
Non-Hispanic White	0,1	23.50	—
African American	0,1	39.33	—
Cuban	0,1	21.10	—
Non-Cuban Hispanic	0,1	16.07

Note. N = 417. SD = standard deviation.

*Significant at .05. **Significant at .01. ***Significant at .001 (two-tailed t-test of mean differences in W1 and W2 variables).

Perceived stigma is measured by a 7-item, standardized index (W1 α = .91) that was developed to assess feelings of devaluation specifically associated with a physical limitation. It is, thus, unlike previous general perceived stigma measures because its point of reference (i.e., physical limitation) is made explicit to respondents. It is also unlike previous health-related perceived stigma inventories, which focus on discrete health conditions, because it is based on the experience of physical limitation, generally defined.

Drawing on items included in previous perceived stigma indices (i.e., Jacoby, 1994; Link, Cullen, Struening, Shrout, & Dohrenwend, 1989), the items included in this instrument were further developed with input from focus groups conducted among people with chronic health conditions. The data gathered from focus group volunteers provided consensus support for the 7 items included in this measure. Factor analysis further supports the inclusion of these items in a single index. Factor loadings for the items included in this index, presented as Table 2, reveal that they load on a single factor. A scree test of the incremental variance accounted for by additional factors (not presented) also indicates that there is one dominant factor underlying these items.

Table 2.

Factor Analysis of Items Measuring Perceived Stigma (W1).

Items and Factor Loadings	Factor 1	Factor 2	Factor 3
People stare at you because of your physical limitation	.658	.204	.136
People avoid close contact with you because of your physical limitation	.683	.173	−.224
Your physical appearance makes you feel embarrassed or ashamed	.737	.142	−.082
People act as if your physical limitation is somehow your fault	.805	−.372	−.131
People act as if having a physical limitation is a sign of personal weakness	.701	−.198	.049
Your physical limitation makes you feel different from other people	.681	.175	−.005
Some people make rude comments or are insensitive about your physical limitation	.729	−.100	.291

Note. N = 417. Extraction method: Principal axis factoring with orthogonal rotation; rotation converged in five iterations.

Age, level of functional limitation, four measures of stressor exposure, and three measures of psychosocial coping resources are included as independent variables. All analyses control for the sociodemographic characteristics of gender, socioeconomic status, and race/ethnicity. All sociodemographic measures are based on W1 reports. For the remaining variables, baseline (W1) levels and changes from W1 to W2 (Δ Variable = W2 Value − W1 Value) are examined. Higher values on the change measures reflect greater change from W1 to W2, with positive values reflecting increases and negative values reflecting decreases. The t-tests of differences between mean values from W1 to W2, as reported in Table 1, reveal few significant differences, suggesting relative stability in the predictor variables from W1 to W2.

Age

Age is employed as a continuous measure in years.

Level of functional limitation

The measure of functional limitation, introduced by Turner and colleagues (Brown & Turner, 2010; Gayman, Turner, & Cui, 2008), is based on the models of disability proposed by the World Health Organization (2001). The measure combines indicators of physical mobility, instrumental daily activities, and basic activities of daily living, an approach which provides a relatively comprehensive picture of functional abilities and limitations, capturing variations at both the severe end and the more able end of the physical functioning spectrum. Pooling from several previously employed measures (see Brown & Turner, 2010, for a complete list), this standardized measure (α = .91) is based on 19 questions gauging the level of functional limitation, ranging from not at all (1) to completely (5).

Stressor exposure

Four additional dimensions of stressor exposure are assessed with previously validated measures: major life events (41 items); recent life events (32 items); chronic stress (39 items); and major and day-to-day discrimination (16 items). Major and recent life events are indexed with Turner and Avison’s (2003) measure that includes experiences with major but not violent stressors (e.g., parental divorce and failing a grade in school), life traumas (e.g., rape, physical and emotional abuse and being injured with a weapon), witnessing violence, receiving information about bad events, and the death of relatives or close friends. Chronic strains are measured with an index adapted from Wheaton’s (1994) inventory, modified to better capture the kinds of enduring stressors older individuals are likely to experience, and first presented by Turner and Avison (2003). The items fall into seven categories: General or ambient problems, work/employment, relationships, parenting, family, social life and recreation, and health concerns. Major and day-to-day discrimination are measured with Williams, Yu, Jackson & Anderson (1997) inventories (8 items each), which consider major experiences of unfair treatment, such as being fired or denied housing, as well as more routine or relatively minor experiences, such as being treated with less courtesy than others or being insulted. It should be noted that the items included in these indices were not asked in reference to any particular social status the respondents might occupy. Consistent with common practice, each score is a standardized count of the number of stressors reported.

Psychosocial coping resources

Three coping resources are considered: social support, mastery, and self-esteem. Assessment of social support is based upon the widely used Provisions of Social Relations Scale, for which evidence of both reliability and construct validity is available (e.g., Turner & Marino, 1994). Participants were asked to indicate whether each of the eight statements about support from friends and each of the eight statements about support from family were very true, moderately true, somewhat true, or not at all true (such as knowing your friends/family will always be there, feeling very close to your friends/family, and feeling your friends/family really care about you). The index is a standardized sum of these 16 items (α = .91).

Mastery is measured with the 7-item scale developed by Pearlin and Schooler (1978). The index is a summed, standardized index (α = .78) assessing the extent to which respondents feel they have control over the things that happen in their lives, are able to solve problems, can change important aspects of their lives, feel helpless (reversed), feel pushed around (reversed), are responsible for what happens in their future, and can do anything they set their mind to. Responses to each item range from strongly disagree (1) to strongly agree (5). Self-esteem is indexed with a shortened version (α = .70) of Rosenberg’s (1981) measure drawn from 6 items concerning whether respondents feel they have a number of good qualities, are a person of worth at least equal to others, are able to do things as well as most other people, have a positive self-attitude, are satisfied with themselves, and are inclined to feel they are a failure (reverse coded). Responses to each item range from strongly disagree (1) to strongly agree (5).

Sociodemographic variables

Gender is coded 1 for females and 0 for males. Socioeconomic status is estimated in terms of three components—income, education, and occupational prestige level (Hollingshead, 1957). This measure was selected because information on household income could not be obtained for 15% of the sample. Scores on these three dimensions are standardized, summed, and divided by the number of measures on which each respondent provided data. Race/ethnicity is a dummy variable including non-Hispanic Whites (n = 98), African Americans (n = 164), Cubans (n = 88), and non-Cuban Hispanics (n = 67). The “non-Cuban Hispanic” designation primarily represents people from Central America. In all regression analyses, non-Hispanic Whites represent the reference category.

Analyses controlling for the prior lifetime occurrence of major depressive disorder employ items from a version of the Composite International Diagnostic Interview largely identical to that employed in the National Comorbidity Study Replication and the World Health Organization–sponsored World Mental Health Study (Kessler et al., 2005). These items gauge whether respondents ever experienced symptoms of depression every day or nearly every day, which impaired their daily activities or caused other impairment, for a period of 2 weeks or longer.

Analytic Strategy

This analysis utilizes residual change regression techniques (Allison, 1990) to examine the extent to which changes in perceived stigma from W1 to W2 are influenced by age and changes in stressor exposure and coping resources. It should be noted that the effects of major life events are only assessed at W1 because events occurring between the two waves of the study are represented in the W2 recent life events measure.

Five nested regression models are presented to consider the relative impact of each of these sets of factors. Model 1 considers the lagged effects of perceived stigma measured at W1 on perceptions of stigma at W2 and the effect of age, net of the other social status characteristics examined. Model 2 introduces the level of functional limitation to examine its role in predicting variation in perceived stigma. Model 3 includes W1 measures of stress exposure and changes in these factors from W1 to W2. Similarly, Model 4 introduces W1 measures of the psychosocial coping resources and changes in these resources from W1 to W2. In Model 5, the possibility that the influence of stress exposure and coping resources is an artifact of their association with the prior occurrence of major depressive disorder is assessed.

To investigate whether any observed effects based upon age are influenced by the effects of the stressors and psychosocial coping resources examined, interaction terms for age by both W1 and change measures of each form of stressor exposure and coping resource are introduced one at a time into the full model (Model 5). Finally, to test whether functional limitation and other forms of stress exposure may interact with the psychosocial coping resources examined in the prediction of perceived stigma, centered interaction terms for both W1 and change measures of functional limitation and stressor exposure by W1 and change measures of the coping resources are introduced one at a time into the full model (Model 5).

Results

The correlation matrix presented as Table 3 provides preliminary evidence that both stressor exposure and psychosocial resources may be useful in understanding variation in perceived stigma. Perceived stigma is positively correlated with the level of functional limitation and the experience of major life events and negatively correlated with mastery and self-esteem. It is also noteworthy that no significant age variation in perceived stigma is observed.

Table 3.

Correlation Matrix of Perceived Stigma (W2) and Independent Variables (W1)^a.

	1	2	3	4	5	6	7	8	9	10	11
1. Perceived stigma (W2)	1.000
2. Age	–.035	1.000
3. Functional limitation	.239*	.223*	1.000
4. Major life events	.143*	–.209*	–.002	1.000
5. Recent life events	.006	–.191*	–.068	.275*	1.000
6. Major discrimination	.073	–.229*	–.056	.337*	.213*	1.000
7. Day-to-day discrimination	.012	–.258*	–.028	.194*	.127*	.322*	1.000
8. Chronic strains	.006	–.219*	–.059	.334*	.428*	.310*	.256*	1.000
9. Social support	–.048	.084	.008	–.212*	–.066	–.119*	–.096*	–.145*	1.000
10. Mastery	–.174*	–.080	–.216*	–.119*	–.056	–.036	–.048	–.218*	.230*	1.000
11. Self-esteem	–.187*	.096*	–.180*	–.200*	–.022	–.077	–.102*	–.098*	.274*	.288*	1.000

Note. N = 417. ^a Perceived stigma is measured at W2; all other variables are measured at W1.

*Significant at .05.

The regression analysis presented as Table 4 further evaluates the significance of these factors for perceived stigma. Consistent with the zero-order correlations presented in Table 3, significant age differences are not observed, net of the control variables (Model 1). These analyses further reveal that greater functional limitation and increases in limitation are associated with increases in perceived stigma (Model 2). When the effects of level of limitation are accounted for, age also emerges as a significant predictor of perceived stigma. Of the other forms of stressor exposure considered in Model 3, only day-to-day discrimination is associated with perceived stigma. Model 4 further reveals that greater self-esteem and mastery and increases in these resources are associated with decreases in perceived stigma.

Table 4.

OLS Regression of Perceived Stigma on Age, Functional Limitation, Stressor Exposure, and Psychosocial Resources.

	Model 1		Model 2		Model 3		Model 4		Model 5
	Metric Coefficient	β Coefficient	Metric Coefficient	β Coefficient	Metric Coefficient	β Coefficient	Metric Coefficient	β Coefficient	Metric Coefficient	β Coefficient
Perceived stigma W1	.384***	.307	.222***	.178	.210***	.168	.203**	.162	.202**	.162
Age	.003	.038	–.010**	–.132	–.009**	–.117	–.011**	–.137	–.011**	–.137
Functional limitation W1			.495***	.507	.482***	.494	.447***	.457	.447***	.457
Δ Functional limitation			.578***	.499	.560***	.485	.527***	.456	.527***	.456
Major life events W1					.074	.068	.089	.082	.089	.082
Recent life events W1					.068	.061	.058	.052	.058	.052
Δ Recent life events					.010	.013	.003	.004	.003	.004
Major discrimination W1					.038	.035	.017	.016	.017	.016
Δ Major discrimination					.044	.044	.011	.010	.011	.010
Day-to-day discrimination W1					.061	.056	.050	.046	.050	.046
Δ Day-to-day discrimination					.126**	.141	.121**	.136	.121**	.136
Chronic strains W1					.038	.035	.027	.025	.027	.025
Δ Chronic strains					.053	.055	.061	.063	.061	.063
Social support W1							.126	.103	.126	.104
Δ Social support							.106	.106	.105	.106
Mastery W1							–.077	–.065	–.076	–.065
Δ Mastery							–.027	–.019	–.019	–.019
Self-esteem W1							–.146*	–.115	–.149***	–.115
Δ Self-esteem							–.230***	–.231	–.230***	–.231
Major depressive disorder									.002	.001
Control variables
Gender (1 = female)	–.009	–.003	–.142	–.059	–.111	–.046	–.028	–.011	–.028	–.011
Socioeconomic status	–.018	–.014	–.046	–.037	–.035	–.028	–.002	–.001	–.002	–.001
African American	.142	.058	–.044	–.018	–.044	–.018	.011	.005	.011	.005
Cuban	.223	.077	.133	.046	.185	.064	.205	.071	.205	.071
Non-Cuban Hispanic	–.040	–.012	–.085	–.026	–.056	–.017	–.067	–.021	–.067	–.021
Constant	–.058		.798***		.716**		.806**		.768**
R ²	.099		.353		.373		.417		.417
R ² Change^b	–		.254***		.020*		.015*		.000

Note. N = 417. OLS = ordinary least squares. ^aStandard errors not presented due to space considerations. ^bWald tests were used to determine whether changes in R ² are significant.

*Significant at .05. **Significant at .01. ***Significant at .001.

Model 5 reveals that major depressive disorder is not significantly associated with perceived stigma and the effects of one’s level of limitation, stress burden, and available coping resources do not appear to be an artifact of the prior occurrence of this disorder. The β coefficients obtained in the full model (Model 5) also indicate that, of the range of factors considered, greater functional limitation and increases in limitation are the strongest predictors of increases in perceived stigma. To a lesser extent, age, day-to-day discrimination (Δ), and self-esteem (W1 and Δ) also influence perceptions of stigma. Older age, greater self-esteem, and increases in self-esteem predict decreases in stigma, whereas increases in day-to-day discrimination predict increases in stigma.

The final step is to test the hypothesis that age, functional limitation and other stressor exposure, and psychosocial coping resources may interact in the prediction of perceived stigma. Interaction terms, as noted, are introduced one at a time into the full model (Model 5). Significant interaction coefficients are presented as Table 5. These tests first reveal that greater age is associated with less of a decline in perceived stigma over the study period in the context of greater functional limitation and increases in limitation. Age is not found to interact significantly with the other forms of stressor exposure or the coping resources considered.

Table 5.

Interaction Terms from OLS Regression of Perceived Stigma on Age, Functional Limitation, Stressor Exposure, and Psychosocial Resources.

	Metric Coefficient	β Coefficient
Age × Functional Limitation (W1)	–.009***	–.649
Age × Functional Limitation (Δ)	–.011***	–.609
Functional Limitation (Δ) × Mastery (W1)	–.093**	–.091
Functional Limitation (Δ) × Mastery (Δ)	–.064**	–.075
Major Life Events (W1) × Mastery (W1)	–.079*	–.064
Recent Life Events (W1) × Self-Esteem (W1)	–.082*	–.072
Recent Life Events (W1) × Self-Esteem (Δ)	–.115**	–.111
Recent Life Events (Δ) × Self-Esteem (Δ)	–.069*	–.099
Day-to-Day Discrimination (W1) × Mastery (W1)	–.082**	–.088
Day-to-Day Discrimination (W1) × Mastery (Δ)	–.041*	–.047
Day-to-Day Discrimination (Δ) × Mastery (W1)	–.131***	–.177
Day-to-Day Discrimination (Δ) × Mastery (Δ)	–.089***	–.127
Day-to-Day Discrimination (Δ) × Self-Esteem (W1)	–.062*	–.068

Note. N = 417. OLS = ordinary least squares.

*Significant at .05. **Significant at .01. ***Significant at .001.

Findings further reveal that functional limitation is associated with significantly less of an increase in perceived stigma in the context of high mastery (W1) and increases in mastery. Post hoc analysis, presented as Figure 1, illustrates that greater mastery provides the greatest benefit for those with greater increases in functional limitation over time. For those with average or lower levels of functional limitation, the effect of these resources appears more modest or negligible.

Figure 1.

Predicted functional limitation contrasts in the effects of mastery on perceived stigma (estimated from Model 5; N = 417). Note: Level of Limitation (Δ) × Mastery (W1; β = −.609, p < .001).

Regarding the other forms of stressor exposure considered, it is striking that several of the significant interactions include stressors that do not have significant main effects on perceived stigma (i.e., major life events, W1 recent life events, and W1 day-to-day-discrimination). Many of these interactions are with mastery (W1 and Δ), which also does not bear a significant direct effect on perceived stigma, suggesting that the effects of these factors are largely interdependent. The significant interactions between stressors and coping resources reveal a pattern similar to that reported with respect to the level of functional limitation. That is, greater levels of stressor exposure and increases in stressor exposure are associated with less stigma among those who report higher levels of coping resources or increases in these resources over time.

Discussion

This study introduces a measure of perceived stigma associated with chronic health conditions to assess whether age, level of functional limitation and exposure to other stressors, and the availability of coping resources influence variation in perceived stigma over a 3-year period and the form this influence takes (i.e., independent and/or interdependent). The findings reported extend previous research in several important ways.

First, the findings clearly reveal that multiple processes influence perceptions of stigma among people with chronic health conditions over time. Drawing from stress process research, which demonstrates that social status, level of functional limitation and other stressor exposure, and the availability of coping resources directly affect various health outcomes (Brown & Turner, 2010; Turner & Noh, 1988; Yang, 2006), similar effects were predicted with respect to perceived stigma. This hypothesis is partly supported. Greater functional limitation and increases in limitation and day-to-day discrimination predict increases in perceived stigma over the study period, whereas greater self-esteem and increases in self-esteem predict decreases (effects that do not appear to be an artifact of the occurrence of major depressive disorder). Age emerges as a significant predictor of decreases in perceived stigma when functional limitation is controlled. Presumably, this is because—level of limitation notwithstanding—experiencing a chronic health condition is generally considered normative and, thus, less stigmatizing in later life (Borawski et al., 1996; Kelley-Moore et al., 2006).

The findings also demonstrate the relative significance of each set of predictors for changes in perceived stigma over the study period. Of the range of factors considered, greater functional limitation and increases in limitation are the strongest predictors of increases in perceived stigma. Age, day-to-day discrimination, and self-esteem occupy intermediary positions. These findings, thus, support the assertion that multiple processes influence variation in perceived stigma, adding the specification that something about the experience of functional limitation is particularly relevant in understanding this variation. Further study of the mechanisms driving the association between functional limitation and perceived stigma is recommended.

The longitudinal nature of this study additionally captures the importance of changes in risk and protective factors for changes in perceived stigma among people with chronic health conditions. Specifically, results indicate that it is when one’s level of functional limitation worsens, there is an increase in discriminatory experiences in one’s daily life, and one’s sense of self-worth is diminished so that feelings of stigmatization are greatest. However, because the data employed in this study are from two waves of data collected 3 years apart, they likely provide only a snapshot of the complex processes underlying changes over time in perceived stigma among people with chronic health conditions. It is theorized, for example, that over extended periods of time, perceived stigma can become a self-fulfilling prophecy, as negative interactions create expectations of rejection that adversely influence future social interactions, thereby reinforcing feelings of stigmatization (Jones et al., 1984; Link & Phelan, 2001). Alternately, there is some speculation that perceptions of stigma may decline over time, as a positive restructuring of one’s social circumstances and relationships occur (Fife & Wright, 2000). These possibilities, beyond the scope of the present study, are recommended for future research.

The evidence presented also suggests the need for further study of the synergistic influence of age and risk and protective factors underlying perceived stigma. Results of the interaction tests, first, provide compelling evidence that the links between greater functional limitation and increases in limitation, respectively, and perceived stigma are diminished in the context of advancing age. Although these findings are generally consistent with observations that the experience of poor physical health may be accompanied by fewer feelings of stigmatization among older adults because it is more normative in later life (Borawski et al., 1996; Erler & Garstecki, 2002), further study is recommended to articulate the age- or limitation-specific factors driving this effect.

Interaction tests also demonstrated that mastery and self-esteem are most beneficial in diminishing perceptions of stigma over time when they are present among those with greater functional limitation and stressor exposure. In other words, when these resources are found where they may be needed the most, they appear to have the greatest benefit. In fact, it is apparently only in such circumstances that the majority of these factors are consequential for changes in perceived stigma. The utility of the stress process model employed here is the demonstration that the most significant effects of stressor exposure and coping resources on perceived stigma are interdependent. The more general point for the field is that perceived stigma is not an inevitable consequence of functional limitation and, when it does occur, can be reduced. Examining stigma processes over longer periods of time would also provide a better understanding of how these contingencies shape continuity and change in perceptions of stigma.

Several broader applications of this investigation’s use of the stress process model in examining antecedents of perceived stigma warrant further comment. First, such a model may provide a useful framework for assessing whether similar processes underlie variation in other common forms of stigma. Additionally, because perceived stigma has been conceptualized as a social stressor (Meyer, 2003), it may be included as a predictor of quality of life and other health outcomes relative to other sources of strain and coping responses. Indeed, incorporating perceived stigma in a stress process framework acknowledges that people who occupy disadvantaged social statuses are potentially host to a variety of negative events not experienced by those who do not occupy such statuses and allows for a better understanding of how these experiences influence one’s life circumstances.

The strengths and limitations of the perceived stigma inventory introduced in this analysis should also be noted. The benefit of this measure is that it gauges perceived stigma associated with multiple chronic health conditions, offering an advantage over general stigma inventories or those associated with a specific health condition. Its emphasis on the visibility of one’s physical health symptoms and the discomfort they are believed to cause in others can be seen as both strength and a limitation. Although these factors are described as central components of perceived stigma among people with physical health conditions (Jacoby, 1994; Van Brakel, 2006) and their inclusion offers advantages over general stigma inventories, there is also concern in the literature that the ability to conceal one’s symptoms is an understudied dimension of perceived stigma (Earnshaw, Quinn, & Park, 2012; Quinn & Chaudoir, 2009). It should be cautioned that it is uncertain how the visibility or concealability of one’s symptoms would influence the pattern of findings reported. This matter, beyond the scope of the present study, is recommended for further investigation.

The evaluation of these results should further take into account two cautions. First, the pattern of findings reported may be influenced by the community context of this study. Because the study sample was drawn to be representative of the population of people with chronic physical health conditions in Miami-Dade County, Florida, further study is needed to determine whether the findings reported are generalizable to the broader U.S. population. Second, this study has provided a general assessment of perceived stigma among people with a range of health conditions. Prior work indicates that perceptions of stigma can vary depending upon the type of condition involved and whether one is experiencing a period of health or disability (Earnshaw et al., 2012; Quinn & Chaudoir, 2009). Because this sample was heterogeneous with respect to the health conditions included, individual categories included too few cases to examine these issues. Further consideration of the nature of one’s condition and its visibility or concealability may broaden our understanding of variation in perceived stigma among people with chronic health conditions.

Footnotes

Appendix A

Table A1.

Distribution of Primary Chronic Health Conditions (W1).

Condition	Frequency	%
Heart diseases including rheumatic fever, acute myocardial infarction, subacute and chronic ischemic heart disease, pulmonary heart disease, and others	89	15.9
Osteoarthritis (other than spine)	25	4.5
Osteoarthritis of spine and degenerative disk disease	27	4.8
Rheumatoid arthritis	19	3.4
Arthritis (other)	75	13.4
Spinal cord, multiple sclerosis, peripheral nerve disorders, polio, and primary muscle disease	39	7.0
Back pain, including back problems and whiplash	46	8.2
Cerebrovascular diseases including stroke, brain aneurysm, and brain hemorrhage	20	3.6
Brain substance including parkinsonism, cerebral palsy, and post head injury	23	4.1
Asthma	11	2.0
Emphysema and chronic obstructive pulmonary disease	16	2.9
Blindness—complete and partial	11	2.0
Diabetes mellitus	66	11.8
Acquired deformities of the spine—scoliosis, fusion of the spine	5	0.9
Amputation and other musculoskeletal injury	30	5.4
Metabolic disease and organ disease (other than heart)	20	3.6
Cancer	16	2.9
HIV, hepatitis and other infectious disease	12	2.1
Congenital deformity (not otherwise classified)	3	0.5
Other	6	1.1
Total	559	100

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is supported by grants RO1 DA13292 and RO1 DA016429 from the National Institute of Drug Abuse to R. Jay Turner.

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