Kato et al. Health and Quality of Life Outcomes (2014) 12:179
DOI 10.1186/s12955-014-0179-z

RESEARCH

Open Access

Reliability and validity of the Japanese version of
the Self-Stigma Scale in patients with type 2
diabetes
Asuka Kato1*, Misato Takada2 and Hideki Hashimoto2

Abstract
Background: Self-stigma has been highlighted and researched in relation to patients with chronic illnesses, as it
may have a negative impact on their treatment adherence. However, self-stigma has not yet been investigated inpatients with type 2 diabetes. In order to evaluate the extent to which patients with type 2 diabetes experienceself-stigma, which may result in their poor self-care management, there is a need for a specific tool to measureself-stigma in patients with type 2 diabetes. This study assessed the psychometric properties of a Japanese versionof the Self-Stigma Scale (SSS-J) in patients with type 2 diabetes.
Methods: The reliability and validity of the SSS-J were evaluated using a consecutive sample of 210 outpatientswith type 2 diabetes from university hospitals and from hospitals or clinics specializing in diabetes treatment.
Confirmatory factor analysis was conducted to assess the factors theorized by the original Self-Stigma Scale.
Cronbach’s alpha for internal reliability and Pearson’s correlations for construct validity were used for evaluationof psychometric properties. Pearson’s correlations for test-retest reliability of the SSS-J were also performed.
Results: Confirmatory factor analysis verified the three-factor structure of the SSS-J, consisting of cognitive, affective,
and behavioral subscales. The model fit indices were as follows: the goodness-of-fit index was 0.78, the adjusted
goodness-of-fit index was 0.70, the comparative fit index was 0.88, and the root mean square error of approximation was
0.07. Cronbach’s alpha of the SSS-J was 0.96 (cognitive: alpha = 0.92; affective: alpha = 0.93; behavioral: alpha = 0.83). The
SSS-J was associated with self-esteem (r = −0.43, p < 0.01), self-efficacy (r = −0.38, p < 0.01), and depressive symptoms(r = 0.39, p < 0.01). The 2-week test-retest reliability demonstrated satisfactory stability (r = 0.76, p < 0.01).
Conclusions: The SSS-J is reliable and valid for assessment of the extent of self-stigma in Japanese patients with
type 2 diabetes.
Keywords: Self-stigma, Psychometric assessment, Reliability, Validity, Type 2 diabetes, Japanese

Introduction
Self-stigma is experienced by individuals who have negative
attitudes towards themselves as a result of their condition
and/or characteristics [1,2]. Self-stigma is also referred toas internalized stigma. Conversely, public stigma represents
negative reactions of the general public towards a groupbased on stereotypical attributes that distinguish that groupin society [1,2]. Public stigma is also known as social
stigma. Self-stigma has a negative impact on individuals,* Correspondence: asukakato-tky@umin.ac.jp
1
Division of Social Medicine, Graduate School of Medicine, The University ofTokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
Full list of author information is available at the end of the article

resulting in decreased self-esteem, self-efficacy, life
satisfaction, social adaptation, overall well-being, andsocial networking [1,3-7]. Additionally, this may lead toeither treatment avoidance or diminished treatment
adherence in patients with chronic illnesses [4,8,9].
Chronic illness, in particular type 2 diabetes, requires
a considerable amount of self-management by patientsin their everyday lives. Additionally, type 2 diabetes is
one of the most common chronic illnesses, and its
prevalence has dramatically increased worldwide in thepast two decades [10]. Likewise, the prevalence of type2 diabetes in Japan has been on the rise [11]. As thenumber of patients with type 2 diabetes increases, some© 2014 Kato et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

Kato et al. Health and Quality of Life Outcomes (2014) 12:179

preconceived ideas about their particular characteristics
result in blame being placed on them, because theircondition is considered to be a lifestyle-related disease.
People with type 2 diabetes are often subject to stigmatizing attitudes from the general population. Recently,
public stigma has been highlighted and researched inrelation to type 2 diabetes. According to these studies,public stigma has a negative impact on diabetes selfcare management [12-15]. However, previous studies
have shown that merely perceiving public stigma does
not necessarily lead to self-stigma [1,2]. Self-stigma is
the issue that will impact patients’ behavioral goals
through decreased self-esteem, self-efficacy, and psychological well-being [1,4,7,9]. As a result, patients become
reluctant to seek necessary treatment and there is a reduced
treatment adherence [4,8,9]. Therefore, it is extremely
important to assess the extent to which patients experience self-stigma, so that early medical interventions for
self-esteem and self-efficacy can be provided to avoid suboptimal treatment outcomes. Nevertheless, there has not
yet been a study on self-stigma in patients with type 2
diabetes and how self-stigma could potentially have an impact on their treatment outcomes.
To assess the extent to which patients with type 2 diabetes experience self-stigma, there is a need for a validated
tool to measure this construct. Although a number of validated tools for self-stigma have been developed, most have
only focused on mental disorders [16-19]. The Self-Stigma
Scale was originally developed to quantify and evaluate
concealed self-stigma among various groups of minorities,
such as immigrants and sexual minorities, as well as mental
health patients [20]. Type 2 diabetes is one of the conditions that cannot be detected by looking at patients’ physical appearance. Therefore, patients with type 2 diabetes
can hide their stigmatized condition from the mainstreamof healthy individuals, although they do so with fear of being discovered [14,15]. For this reason, the Self-Stigma
Scale is viewed as the best tool that can be easily adapted
for use with the particularly concealable condition of type 2
diabetes. In this study, we translated the Self-Stigma Scalefrom English to Japanese and examined its reliability andvalidity in patients with type 2 diabetes. Furthermore, we
tested the equivalency between the Self-Stigma Scale (hereafter defined as “the original scale”) and the Japanese version (SSS-J) when assessing patients with type 2 diabetes.

Methods
Development of the SSS-J

Translation procedures were based on the Consensusbased Standards for the Selection of Health Measurement
Instruments checklist [21]. Four steps were followed(Figure 1). Multiple forward and backward translations
were performed by six translators. They were selectedaccording to the following criteria:

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1. There were two forward translators who were both
native Japanese speakers. One translator had
expertise on stigma, and the other was a language
expert but lacked knowledge about stigma.
2. There were four backward translators. Two were
native English speakers, and the other two were
native Japanese speakers. They were all language
experts with no knowledge of stigma or theoriginal scale.
In Step 1, two native Japanese speakers worked independently and translated the original scale into Japanese.
They were fully informed about the objectives of thewhole translation procedure, and forward translated all
the questionnaire items, not word-for-word but withemphasis on the meaning of each item. We then combined these two Japanese translations into one. To amalgamate these Japanese translations, the two translatorsand three authors had discussions to reach a consensus
in terms of the following four criteria: content, semantics, conceptualization, and technical equivalence withthe original scale, as well as cultural adaptations. In Step2, another two native Japanese speakers worked independently and were asked to backward translate the Japanesetranslation in Step 1 into English. We then combined
these two English translations into one by reaching a consensus with the two translators in the same way as in Step
1. Afterwards, two bilingual individuals, whose native language was English, checked for any semantic discrepancies
between the Japanese translation in Step 1 and the backward translation in Step 2. All these backward translators
were blinded to the original scale. In Step 3, the English
translation produced in Step 2 was reviewed by the original
scale developers. Based on suggestions from them, somequestionnaire items were revised through repeated forward
and backward translation procedures (Steps 1 and 2) toreflect the original meaning after translation.
In Step 4, the translation was pretested in cognitive
interviews by five outpatients with type 2 diabetes toensure accessibility and comprehension. They were men
and women aged 30–74 years with different educational
backgrounds ranging from those without a high school
education to those with a bachelor’s degree. According
to their comprehension level of the Japanese translation,some words were altered to even plainer language. Additionally, Japanese patients with type 2 diabetes did notunderstand the direct translation of the term “identity”.
Therefore, with permission of the original scale developers, we replaced the term with a Japanese phrase,“oneself with the illness, diabetes”, while maintaining theconceptual equivalence in the original scale. Thereafter,
we processed Steps 2 and 3 in the same way. Finally, we
obtained permission from the original scale developers
to field test the revised translation.

Kato et al. Health and Quality of Life Outcomes (2014) 12:179

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Figure 1 Flow chart describing the development of the Japanese version of the Self-Stigma Scale. SSS: Self-Stigma Scale.

Testing the SSS-J in type 2 diabetes patients

The SSS-J was tested between November 2013 and March
2014. Consecutive sampling was used to recruit all outpatients with type 2 diabetes who visited a diabetologist on a
specific date at four locations, comprising two university
hospitals (The University of Tokyo Hospital and Teikyo
University Hospital), one non-university affiliated hospital(Mitsui Memorial Hospital), and one non-university affiliated clinic (The Institute for Adult Diseases Asahi LifeFoundation) in Japan. The following patients were excluded: non-native Japanese speakers; those aged 75 years
or older; and those with a serious mental disorder, such as
dementia, that affected their cognition. Additionally, patients who required urgent medical procedures or examinations were excluded.
During enrollment, the purpose of the study was explained by study staff, and informed consent was obtained
from those who agreed to the terms of the study. The SSSJ was self-administered in the majority of the participants.
For those who had either visual loss or poor literacy skills,
an audiotape was provided to read out each question. To
determine the test-retest reliability, all participants tookhome another SSS-J questionnaire to complete after
2 weeks and this was mailed back to our office. Reminder
phone calls were made up to two times as necessary.
The sample size was calculated based on the number required to perform the factor analysis for the psychometricassessment of the scale. Because it had 39 items, theminimal sample size was 195 based on a participant-toitem ratio of 5:1 [22].
This study was approved in advance by the Research
Ethics Committee of The University of Tokyo Graduate
School of Medicine and Faculty of Medicine.
Measures

A self-administered questionnaire was used to assess
diabetes-related complications and hemoglobin A1c. The

number of complications was calculated with reference tothe Diabetes Complications Index (DCI) [23]. The score
ranged from 0 to 6. Participants were asked to fill out theirhemoglobin A1c levels based on a copy of laboratory
results received that day.
SSS-J scale

The SSS-J comprises 39 items that allow four responses
in a Likert scale: strongly disagree, disagree, agree, andstrongly agree. The responses are afforded a score of 0,1, 2, and 3, respectively. The total possible scores have arange of 0–117. A higher score represents a higher levelof self-stigma.
We predicted that the SSS-J would be negatively associated with several self-identity measures, such as selfesteem and self-efficacy, and that it would also be related
to greater levels of depressive symptoms. Our predictions
in a Japanese sample of patients with type 2 diabetes were
informed by the results of a previous study [20]. For comparison, participants completed the following measures in
addition to the SSS-J.
Self-esteem

The Rosenberg Self-Esteem Scale was used to assess thelevel of self-esteem [24,25]. It is a widely accepted scalebecause of its high reliability and validity. It contains 10
items scored on a 4-point Likert scale from 1 (strongly
disagree) to 4 (strongly agree). Five negative items werereverse-scored to compute the total scores of individual
participants. In this study, it had an internal consistencyof 0.79.
Self-efficacy

The General Self-Efficacy Scale was applied to assess individual strength in general self-efficacy across a variety
of settings in everyday life [26]. It is reliable and valid,
and is commonly used to measure self-efficacy in Japan.

Kato et al. Health and Quality of Life Outcomes (2014) 12:179

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It is a 16-item scale using dichotomous (yes/no) questions.
In this study, it had an internal consistency of 0.84.

questionnaire containing the SSS-J items 2 weeks later,
producing a response rate of 89.0%.

Depressive symptoms

Descriptive statistics for the SSS-J

The nine-item depression module of the Patient Health
Questionnaire (PHQ-9) was used to assess depressive
symptoms during the previous 2 weeks [27,28]. It is a reliable and valid measure of depression severity for clinicaluse. Each item is scored on DSM-IV (Diagnostic andStatistical Manual of Mental Disorders-IV) criteria from 0(not at all) to 3 (nearly every day). In this study, it had aninternal consistency of 0.86.

The sociodemographic and clinical characteristics of theparticipants are shown in Table 1. There were 169 maleparticipants (80.5%) and 41 female participants (19.5%),
and the mean age was 60.1 ± 10.0 years. The mean duration of type 2 diabetes was 13.3 ± 9.6 years and the meanhemoglobin A1c level was 7.3 ± 1.2%. The number ofcomplications was calculated as the simple sum of the six
complications from the DCI [23]. The score range was 0–6, and 62.4% of participants had no complications. Table 2

Statistical analysis

The mean and standard deviation of each item of the
SSS-J were determined. Cronbach’s coefficient alpha wascalculated to assess the internal reliability of each subscale defined by the original scale. Confirmatory factor
analysis was conducted on the SSS-J to confirm that thethree-factor model theorized in the original scale would
achieve the best fit for the data in Japanese patients with
type 2 diabetes. Model fitness was assessed based on the
maximum likelihood method by using the following fit
indices: goodness-of-fit index (GFI), adjusted goodnessof-fit index (AGFI), comparative fit index (CFI), and root
mean square error of approximation (RMSEA). The
model was built using three self-stigma subscales, which
consisted of 19 cognitive, 14 affective, and six behavioral
items as observed variables. The construct validity was
examined with Pearson’s correlations in the Self-Esteem,
General Self-Efficacy, and PHQ-9 scales.
All analyses were conducted with SPSS version 18.0
(SPSS Japan Inc., Tokyo, Japan), except for the confirmatory factor analysis, which was performed using AMOS
version 18.0 (SPSS Japan Inc., Tokyo, Japan).

Table 1 Sociodemographic and clinical characteristics ofparticipants (n = 210)

Results
Physicians recruited 259 patients with type 2 diabetes
and written informed consent was obtained from 218,
giving a response rate of 84.2%. Of these patients, 217
completed the questionnaire (one patient declined). The
percentage of missing data was zero for all questionnaire
items. In the analysis, we excluded five participants who
answered all 39 items of the SSS-J with a “strongly
disagree” response, because they responded strongly tostigma, and we did not know whether the scale could
measure what it was originally intended to assess. We
also excluded two participants who had vision loss andcompleted the questionnaire with the aid of an audiotape, because they used different cognitive tasks fromthose who were able to answer all of the questionnaire
items on their own. Therefore, 210 participants were
included in our final analysis. Of these remaining participants, 187 answered and returned the second

Patient characteristics

N (%) or mean (±SD)

Sex:
Men

169 (80.5)

Women

41 (19.5)

Age (years):

60.1 (± 10.0)

Marital status:
Married152 (72.4)

Unmarried/Divorced/Bereaved

58 (27.6)

Employment:
Full-time work

121 (57.7)

Part-time work

50 (23.8)

Retired/not working

36 (17.1)

Others3 (1.4)Highest education:
Have not graduated high school

16 (7.6)

High school

66 (31.4)

Technical/junior college

34 (16.2)

Bachelor’s degree or higher

94 (44.8)

Duration of diabetes (years):

13.3 (± 9.6)

Primary treatment:
Oral hypoglycemic agents123 (58.6)

Insulin injections

15 (7.1)

Insulin injections and oral hypoglycemic agents45 (21.4)

Other injectable medications (other than insulin) 14 (6.7)
Lifestyle

13 (6.2)

HbA1c (%):

7.3 (± 1.2)

Numbers of diabetes-related complications:0131 (62.4)

1

53 (25.2)

2

16 (7.6)3

9 (4.3)4

1 (0.5)

SD: standard deviation; HbA1c: glycated hemoglobin.

Kato et al. Health and Quality of Life Outcomes (2014) 12:179

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Table 2 Scores of items in the Japanese version of the Self-Stigma Scale in type 2 diabetes patients
COGNITIVE

AFFECTIVE

BEHAVIORAL

Being a ___ takes away many opportunities from me. (29)

M

SD

1.85

0.67

I think that I am less competent than ordinary people because I am a ___. (26)

1.59

0.57

I feel that my life is unenjoyable because of myself with the illness, ___. (31)

1.81

0.69

No matter how hard I work, I cannot match others because of myself with the illness, ___. (30)

1.64

0.55

Who I am: having the illness, ___, is a heavy burden to me. (38)

2.17

0.78

I have low expectations in life because I am a ___. (18)

1.80

0.64

I am not qualified to compete with others because I am a ___. (27)

1.54

0.54

Who I am: having the illness, ___, is a stigma in my life. (13)

1.92

0.73

Who I am: having the illness, ___, has a negative impact on my financial situation. (35)

2.15

0.83

I am inferior to others because I am a ___. (21)

1.66

0.58

Who I am: having the illness, ___, causes inconvenience on my daily life. (34)

2.13

0.76

I cannot measure up to ordinary people because I am a ___. (10)

1.68

0.65

I cannot change myself with the illness, ___. (11)

1.90

0.67

I lower my standards of living because I am a ___. (6)

1.90

0.65

My life is meaningless because I am a ___. (4)

1.63

0.51

I need assistance from others because I am a ___. (12)

1.77

0.67

My social interactions are limited because I am a ___. (2)

2.04

0.66

It is quite normal for me to be alienated by others because I am a ___. (5)

1.55

0.51

I feel much stressed because I am a ___. (1)

2.49

0.73

I cannot feel confident about who I am because of myself with the illness, ___. (33)

1.74

0.61

I am worried about who I am: having the illness, ___, would create obstacles to me. (25)

1.90

0.74

I have negative feelings about myself with the illness, ___. (23)

1.79

0.68

I am unhappy because I am a ___. (32)

1.80

0.69

I feel helpless because I am a ___. (37)

1.59

0.57

I am discouraged because I am a ___. (28)

1.84

0.71

I hate myself because I am a ___. (24)

1.89

0.71

I get embarrassed because of myself with the illness, ___. (39)

1.68

0.68

I feel angry because I am a ___. (22)

1.96

0.75

I feel uncomfortable being a ___. (17)

2.22

0.80

I feel sorry that I am a ___. (8)

1.98

0.73

I feel there is nothing I can do about being a ___. (16)

1.92

0.74

I fear that people around me would find out that I am a ___. (15)

1.75

0.78

I am ashamed of being a ___. (3)

1.99

0.72

I avoid interacting with others because I am a ___. (36)

1.55

0.56

I keep my distance from others because I am a ___. (19)

1.57

0.62

I give up on myself because I am a ___. (14)

1.69

0.63

I hide myself with the illness, ___. (20)

1.66

0.77

I make friends only with people who are in the same condition as mine. (9)

1.48

0.56

I dare not to make new friends because they might find out that I am a ___. (7)

1.53

0.58

____ in each question item was replaced by either “diabetes” or “patient with diabetes”. The numerical values in parentheses after each question item reflect theorder in which the items appeared as the patients completed the SSS-J. Questionnaire items within each subscale are listed in descending order of factor loading.
M: mean; SD: standard deviation; SSS-J: Self-Stigma Scale, Japanese version.

indicates the means and standard deviations for each itemof the SSS-J questionnaire. In the SSS-J, the mean scores
were lower and the standard deviations were smaller inour patients for all items compared with the scores formental health patients using the original scale. The score
distributions were not found to be highly skewed.

Kato et al. Health and Quality of Life Outcomes (2014) 12:179

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Confirmatory factor analysis

The results of the confirmatory factor analysis are demonstrated in Figure 2. All path coefficients were significant.
The model fit indices were as follows: GFI = 0.78, AGFI =0.70, CFI = 0.88, and RMSEA = 0.07. The goodness-of-fit
indices for the confirmatory factor analysis were acceptable.
There was a relatively good fit between the three-factor
model and the observed data. The GFI in this sample wasχ2 = 1189.46
GFI = 0.78
AGFI = 0.70
CFI = 0.88
RMSEA = 0.07

CognitiveeC

below 0.9. However, the GFI depends on the total numberof observed variables [29]. As the SSS-J was tested using 39
items, the GFI in this sample would be less than 0.9. However, all factor loadings based on the three-factor model ofthe 39 items were higher than the general standard (0.4) inthis sample. Additionally, the CFI value of 0.88 is close to0.90, indicating a relatively good fit [30]. The RMSEA valueof 0.07 is in the reasonable fit range of 0.05–0.08 [31].

0.45
0.47
0.57
0.45
0.57
0.60
0.59
0.51
0.65
0.66
0.62
0.70
0.66
0.71
0.70
0.70
0.62
0.63
0.67

0.98

Self-stigma

0.94

AffectiveeA
0.89

Behavioral

0.52
0.60
0.55
0.58
0.65
0.66
0.76
0.70
0.77
0.71
0.76
0.78
0.76
0.69

0.45
0.50
0.74
0.77
0.62
0.82

SSS-J 1SSS-J 2

e1

SSS-J 4SSS-J 5SSS-J 6SSS-J 10SSS-J 11SSS-J 12SSS-J 13SSS-J 18
SSS-J 21SSS-J 26SSS-J 27
SSS-J 29SSS-J 30SSS-J 31SSS-J 34
SSS-J 35SSS-J 38e4

SSS-J 3SSS-J 8SSS-J 15SSS-J 16
SSS-J 17SSS-J 22SSS-J 23
SSS-J 24SSS-J 25SSS-J 28
SSS-J 32

e2

e5
e6
e10
e11
e12
e13
e18
e21
e26
e27
e29
e30
e31
e34
e35
e38
e3
e8
e15
e16
e17
e22
e23
e24
e25
e28
e32

SSS-J 33
SSS-J 37

e33

SSS-J 39

e39

SSS-J 7SSS-J 9SSS-J 14SSS-J 19SSS-J 20SSS-J 36

e7

e37

e9
e14
e19
e20
e36

eB
Figure 2 Results of the confirmatory factor analysis of the Japanese version of the Self-Stigma Scale in patients with type 2 diabetes.
GFI: goodness-of-fit index; AGFI: adjusted GFI; CFI: comparative fit index; RMSEA: root mean square error of approximation.

Kato et al. Health and Quality of Life Outcomes (2014) 12:179

Internal consistency

The internal consistency of the SSS-J was excellent: Cronbach’s alpha = 0.96. The internal consistency of each conceptual dimension of the SSS-J ranged from acceptable toexcellent: cognitive (Cronbach’s alpha = 0.92), affective(Cronbach’s alpha = 0.93), and behavioral (Cronbach’s
alpha = 0.83). This demonstrated excellent internalconsistency reliability, indicating adequate interrelations
between the items of the scale.
Test-retest reliability

Test-retest reliability was determined by comparing responses to the SSS-J among 187 participants (89.0%) who
completed the questionnaire at home after a 2-week interval.
The correlation coefficient for test-retest reliability was 0.76
(p < 0.01). This demonstrated acceptable reproducibility. A
correlation coefficient range of 0.7–0.8 is acceptable [32].
Construct validity

Significant Pearson’s correlations were observed when analyzing the scores in the SSS-J and the other comparable
scales. The Rosenberg Self-Esteem (r = −0.43, p < 0.01) and
the General Self-Efficacy (r = −0.38, p < 0.01) scales were
negatively correlated with the SSS-J, whereas the PHQ-9
demonstrated a positive correlation (r = 0.39, p < 0.01).
This was consistent with predictions based on the resultsof the original scale.
For the participants in this study, the median self-stigma
score was 75 with a range of 40–109, and the median depressive symptoms score was 3 with a range of 0–25.

Discussion
This is the first study to examine the reliability and validityof the Japanese version of the Self-Stigma Scale to assess
the extent of self-stigma among individuals with type 2
diabetes. The SSS-J was developed based on several forward and backward translations with cross-cultural validation. All the questionnaire items were comprehensible byboth elderly people and individuals with lower educational
levels. The SSS-J also offered reliable and valid determination of psychometric properties as well as the relevant
structure of self-stigma consisting of cognitive, affective,
and behavioral subscales in the same manner as theoriginal scale [20].
The results indicated that the SSS-J consistently constructed the three-factor model as in the original scale
while using a different focus group and language. Furthermore, they indicated that each subscale had adequate
internal consistency. This demonstrates that the SSS-J canbe used to assess self-stigma among Japanese people with
type 2 diabetes. It should be noted that among people with
type 2 diabetes, items with higher factor loadings differedfrom those in the original scale (Table 2).

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In the SSS-J, the mean scores in all questionnaire items
were lower among patients with type 2 diabetes than in
the original scale that targeted minorities with concealed
self-stigma, such as mental health patients. As previous
studies have shown, it is speculated that those patients
who have a high educational attainment, whose conditions
are less severe, and whose treatment is sustained are lesslikely to develop self-stigma [33-35]. Our sample consistedof a higher percentage of these subgroups. However, wecannot conclude anything definite about the possible
reasons for the low scores to explain the current data. Further research is needed to determine whether patientswith type 2 diabetes do indeed have lower scores in termsof self-stigma when compared with patients with otherchronic physical illnesses, as well as mental illnesses.
There are some limitations to this study. First, the participating patients with type 2 diabetes were recruitedfrom specialist hospitals/clinics. Patients who were seen
regularly by a primary care doctor were not included, andneither were those who were not treated after diagnosis.
Further research in a more representative population isneeded in the specialty field, and also in primary care settings. Second, a sample with similar disease characteristics
as used in the original scale, i.e., patients with mental
disorders, was not tested. Further research using such asample is needed to assess the cross-cultural validity of
the SSS-J more precisely. Third, diabetes-related complications were self-reported by participants, and the data
were likely to be under-reported. To overcome the limitation of this self-reported assessment, an alternative variable, the duration of type 2 diabetes, was used to proxy forthe severity of the illness. Fourth, there was a sex imbalance in our sample, as the percentage of men was 80.5%
and the percentage of women was 19.5%. Although theprevalence of type 2 diabetes is higher among men(15.3%) than women (7.3%) in Japan [11], it is not known
exactly why we had such a large number of male respondents, compared with female respondents. Finally, wewere not able to assess the concurrent validity of selfstigma, as no similar validated scale exists for comparison.
Although there are other generic stigma scales targetingpeople with psychiatric disorders, they do not necessarily
assess the same construct as self-stigma for people withchronic physical illnesses.
Nevertheless, use of this self-administered scale would
be valuable to assess the levels of self-stigma in individual
patients with type 2 diabetes in daily clinical practice. In achronic disease such as type 2 diabetes, patient self-care isnecessary and a validated tool of self-stigma would indicate the need for measures to be taken to eliminate a possible barrier to optimal treatment. In psychiatric patients,
there is evidence that self-stigma reduction programs are
effective in improving their self-esteem, promoting theirreadiness to change their own problematic behavior, andKato et al. Health and Quality of Life Outcomes (2014) 12:179

facilitating their treatment adherence [36-38]. Similar effects may be expected in patients with type 2 diabetes,with improved treatment adherence by lowering levels of
self-stigma through patient education programs.

Conclusions
This study has demonstrated that the SSS-J produces thesame factor structure as the original Self-Stigma Scale
through testing by confirmatory factor analysis. Furthermore, it indicated that the SSS-J could be a useful clinicaltool to help healthcare professionals identify high-risk
self-stigma patients with type 2 diabetes. For clinical useof the SSS-J, given its length, a shorter version should be
developed as this will avoid some redundant items while
incorporating more relevant items. In addition, further
studies are needed to discover the optimum time during
the treatment process to respond to self-stigma in individual patients with type 2 diabetes, as well as the most effective places to assess the extent of self-stigma. With
continual use of the SSS-J, the degree of self-stigma may
be accurately assessed. As a result of these assessments, itwould be possible to provide patients with different treatment strategies in addition to early intervention to help
reduce self-stigma. This could then lead to optimal treatment outcomes.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AK and HH conceptualized and designed the study. AK combined eachforward and backward translation into one by working with the original
scale developers. AK also conducted cognitive interviews with patients forthe unified translation and revised it accordingly with permission from thescale developers. AK acquired, analyzed and interpreted the data, andprepared this paper. MT helped to analyze and interpret the results andrevised the paper. HH interpreted the results and revised the paper. All
authors read and approved the final manuscript.
Acknowledgments
The authors are grateful to Associate Professor Winnie W.S. Mak for allowing
them to translate the original Self-Stigma Scale into Japanese to test it inJapanese patients with type 2 diabetes. They would also like to thank theforward and backward translators, Yuki Takano, Kaori Y. Pinchart, Eriko
Koyama, George R. Harada, and Roseline Yong, most warmly for their kindwork with the translation of the Self-Stigma Scale into Japanese. The authors
would like to acknowledge Professor Takashi Kadowaki (The University ofTokyo Hospital), Professor Shin Fujimori (Teikyo University Hospital), Dr. Akihiro
Isogawa (Mitsui Memorial Hospital), and Dr. Yukiko Onishi (The Institute for
Adult Diseases Asahi Life Foundation) whose help and cooperation permitted
them to recruit the patients for this study. Similarly, the authors would like toexpress their appreciation to all of the study participants. Finally, the authors are
grateful to the many graduate students who assisted them in collecting thequestionnaires.
Author details
1
Division of Social Medicine, Graduate School of Medicine, The University ofTokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. 2Department of
Health and Social Behavior, School of Public Health, The University of Tokyo,
7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
Received: 11 August 2014 Accepted: 22 November 2014

Page 8 of 9

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