Background
Dementia is a syndrome that comprises a collection of symptoms characterised by a decline in, and ultimately a loss of, cognitive functions such as decision-making, attention and awareness, planning, inhibition, learning, memory and language. Dementia is categorised as a major neurocognitive disorder in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition [
1]. There are a number of underlying neuropathologies or neurodegenerative illnesses that ultimately lead to dementia, for example Alzheimer’s disease and vascular disease.
Receiving a diagnosis of dementia presents individuals with both social and psychological challenges where stigma can be a pivotal and powerful negative force shaping people’s experiences [
2]. The recent World Alzheimer Report on Attitudes to Dementia concluded that people living with dementia are stigmatised across many different domains, such as social life, finances, housing, healthcare, intimate relationships, making or keeping friends and being treated unfairly by children or family [
3].
Self-stigma and its impact
Self-stigma, also referred to as internalized stigma, is a cognitive process whereby an individual internalises negative stereotypes and prejudice related to their stigmatised identity [
4]. There is a well evidenced connection between mental health difficulties and the experience of self-stigma which in turn was associated with lower levels of empowerment, self-esteem, hope, self-efficacy, symptom severity, treatment adherence, social support and quality of life [
5,
6]. Self-stigma has also been linked to negative consequences of concealing a diagnosis (e.g. anxiety and depression) and withdrawal from health services [
5,
7,
8].
People with dementia have also been found to be at risk of self-stigma. A recent systematic review found self-stigma to be associated with anxiety and depression, personal control, self-esteem, social support and activity participation [
9‐
11]. More specifically, self-stigma has lasting negative consequences for people living with dementia such as withdrawing from everyday activities or interactions, delays in help-seeking, loss of confidence or feeling inferior [
12‐
16].
Quantifying self-stigma
The measurement of self-stigma in mental health is complex, with a recent review of 57 empirical papers documenting five self-stigma outcome measures for people with a mental health diagnosis [
17]. Authors of the five self-stigma measures reported content validity, however no or little detail was given on other important psychometric properties including internal consistency and convergent validity. A further systematic review examining the efficacy of psychosocial self-stigma interventions for people with schizophrenia-spectrum diagnoses identified six self-stigma measures from 12 studies but, again, these measures were subject to limitations including no of sensitivity to change in seven randomised controlled trials (RCTs). Collectively, both systematic reviews concluded that further refinement of self-stigma measures in line with reliability and validity criteria, careful cultural considerations and condition-specific adaptation with those who have lived experience of the condition are necessary avenues for future research [
17‐
19].
The stigma impact scale
The Stigma Impact Scale (SIS) is the only self-stigma scale that had been previously tested in populations living with dementia [
11]. It has three subscales (social rejection, social isolation, internalized shame) and was based on the adapted Multidimensional Model of Perceived Stigma, which was used to explain self-stigma experienced by people living with Alzheimer’s and Parkinson’s disease [
20]. Recent testing of the SIS in people living with dementia suggests an association between decreased levels of self-esteem and increased levels of internalized shame and social isolation, speaking to the inverse relationship between self-esteem and stigma concepts which has been found in other mental health conditions [
10,
21].
Rationale for study
The intervention that informed present work, Honest, Open, Proud (HOP) is a group-based psychosocial intervention delivered over three sessions to help people with mental health difficulties consider disclosing stigmatised identities (e.g. a diagnosis of schizophrenia) across settings [
21,
22]. HOP has recently undergone adaptation to support people living with dementia [
23], however, there are currently no ‘gold standard’ outcome measures available to evaluate the effectiveness of psychosocial stigma reduction interventions in dementia, with previous studies criticised for not reporting psychometric properties of measures used or using non-standardised outcomes [
11,
24]. As such, there is a need for standardised and psychometrically robust outcome measures developed specifically to evaluate self-stigma for people with dementia. The aim of the current study was to identify, modify and test the feasibility and psychometric properties of existing stigma instruments used in mental health research for use with people living with dementia.
Discussion
This is, to our knowledge, the first study to report the acceptability, suitability and psychometric properties of self-stigma measures for people living with dementia. The results of the small-scale pilot suggest that the Stigma Stress Scale, secrecy subscale of the Stigma Coping Orientation Scale, and Stigma Impact Scale are acceptable for use in a UK population of people living with dementia. Almost all measures had moderate test-retest reliability, suggesting they may be suitable for use as outcomes measures (baseline versus follow-up), and all measures except the SSS total, and the internalized shame subscale, had good internal consistency. Concurrent (criterion) validity with the Stigma Impact Scale was tested for, but did not reach criterion for any correlation. Convergent (construct) validity was established with self-esteem with all correlations in the expected direction.
Findings in the context of existing research
The link between the appraisal of stigma as harmful (perceived harm subscale of the SSS) and social rejection and isolation was supported in the current study. However, the absence of a correlation between perceived harm and internalized shame was not predicted as previous mental health literature has found that internalized shame plays an integral role in shaping stigma experiences [
42,
53]. The SSS may not adequately measure the stigma stress appraisal process for people living with dementia. Further, the internal consistency of the SSS was improved when the subscales were kept separate rather than as one overall score.
The secrecy subscale of the SCOS only correlated with the internalized shame subscale of the SIS, indicating secrecy may be associated more with cognitive components of self-stigmatisation than the more social and overt aspects (social rejection and isolation). Measuring levels of secrecy, therefore, may be a way of operationalising internalized shame rather than measuring the appraisal of stigma (SSS).
The current study found significant negative correlations between the SIS, all three subscales and the RSES, whereas previous work was only able to find this for the internalized shame subscale [
20]. The relationship between self-stigma and self-esteem is well documented in mental health stigma research, but less so in dementia. The current study, therefore, evidences the similarly important role of self-esteem in self-stigma for people living with dementia.
The internalized stigma of mental illness scale (ISMI) was excluded at the stakeholder consultation stage of the current study however it has been a popular measure for use in stigma reduction interventions for mental health (for a review see Wood et al., 2016). Although the ISMI had the highest quality rating of all identified measures, the content would have required significant changes for use in a population of people living with dementia. This speaks to the importance of acknowledging the nuances in the experience of self-stigma between clinical populations. With this in mind, the current study has begun to clarify the potential use of stigma measures in dementia, but efforts to establish specific frameworks (e.g. stress appraisal process in dementia) and theories should underpin the modification process as some measures may perform well in certain clinical populations and not others.
Methodological problems and limitations
The format of participation (online versus face-to-face) may have affected the results as participants may have been more likely to answer in a socially desirable manner if participation took place in person rather than online. In addition to this, four different researchers were involved in administering the instruments during face-to-face participation, potentially affecting inter-rater reliability. However, all researchers were trained in administration of the outcome measures and all had prior experience of working with people with dementia.
Although overall acceptability was satisfied, some participants felt that response categories were too absolute, where the answer would depend on whom the participant was thinking about at the time. For example, “how comfortable do you feel when talking to a friend about dementia?” depended on the “friend” in question, with some participants noting they had told some but not all of their “friends”. Thus, who the participant chose as the referent may have influenced the responses given. However, this feedback can be used to improve measures in the future.
The SIS was the only instrument available that had an existing evidence base for people living with dementia and was therefore used as the ‘gold standard’ measure to assess concurrent validity. However, the SIS may not truly offer a ‘gold standard’ measure as defined by Terwee and Collegues [
19]. For this reason, concurrent validity of the SSS and SsSCOS should be interpreted with caution.
The current study has begun to address the criticisms of previous work, namely the lack of reporting on psychometric properties. However, although previous research has suggested 25 to 40 participants are adequate for preliminary development and piloting measures, [
54] further large-scale, quantitative studies are needed to confirm the psychometric properties of the SSS, SsSCOS and SIS.
Future research
As this study only provided tentative psychometric properties for three self-stigma measures, the next stage is to confirm these properties in a large-scale study and conduct further psychometric analysis to understand each measures sensitivity to change. Further, the various components of self-stigma and how they relate to each other and other mental and physical health concepts should be explored.
Currently, there are no models or frameworks to underpin the investigation of self-stigma in dementia, with little quantitative and qualitative work conceptualizing self-stigma. Work such as this should be established as it will form the basis of quantifying stigma experiences for people living with dementia. In addition, self-stigma in relation to other psychological comorbidities such as depression should be considered in future research.
Some participants were recruited through community groups (e.g. peer support) and others through the JDR database. Although the current study did not aim to quantify the experiences of people living with dementia, rather test the acceptability of doing so, it is important to note that those participants embedded in social groups that have shared experiences of dementia presented very different narratives regarding stigma and dementia to those not embedded in such groups. This may have a significant impact on wellbeing for people with dementia and the relationship between social connectedness, isolation and self-stigma which warrants further attention in future research.
Conclusion
Three self-stigma measures were identified and adapted using a robust four-stage process in which other identified measures were excluded due to poor quality of psychometrics or lack of relevance to dementia. Measures of secrecy, stigma impact and stress appraisal were acceptable for use in a UK population of people living with dementia. However, the psychometric properties were established using only a small sample. Further psychometric analysis is required before such measures can be implemented in psychosocial research.
Acknowledgements
The authors would like to thank experts by experience from the UCL Research Advisory Group, Dr. Josh Stott, Dr. Holly Walton and Dr. Linda Birt for their expert input. We would also like to thank Rebecca Light and Ciara Rafter for their assistance in data collection and all the people who took part in this study.
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