The Association Between Illness Representations, Coping Strategies and Stigma and Treatment Adherence Among People with Type 1 Diabetes in the Arab Society: A Comparison Between Women and Men

Background: Type 1 Diabetes Mellitus (T1DM) is a chronic autoimmune disease resulting from insulin deficiency. Effective management of the disease relies on daily, lifelong self-care efforts. As Alvarado-Martel et al. (2019) emphasized, non-compliance with treatment regimens can lead to severe complications including mortality. Studies show that populations with low socioeconomic status and minorities, like Arabs in Israel, tend to have lower compliance with T1DM management (Zuckerman-Levin et al., 2018; Nonogaki et al., 2019). Studies on other chronic diseases, such as mental disorders, depression, asthma, and AIDS, have found that illness perceptions, stigma, and coping strategies are key variables affecting compliance. However, no study has yet examined the relationship between these variables and patient compliance among T1DM patients from the Arab population, considering gender differences. The proposed study will address these gaps in the literature, utilizing the Self-Regulation Model as the theoretical framework.

Research Objectives: This study aims to examine the relationship between illness representations, stigma, and coping strategies, and patient compliance among T1DM patients aged 18 and over from the Arab population, and to compare gender differences.

Research Methods: A convenience sample of 156 T1DM patients aged 18 and over, split equally between men and women, was recruited from diabetes associations and social networks. Research instruments included: Dependent variable: Patient compliance, measured using the Self-Care Inventory Revised Version (Weinger et al., 2005), assessing self-reported compliance. Independent variables: Illness representations were measured using the Brief Illness Perception Questionnaire (Broadbent et al., 2006); stigma was assessed using the T1DM Stigma Assessment Scale (DSAS; Browne et al., 2017); and coping strategies were measured using the CERQ-Short (Cognitive Emotion Regulation Questionnaire-Short; Garnefski & Kraaij, 2007). Socio-demographic variables included gender, age, education, marital status, and number of children. Clinical characteristics included disease duration, type of treatment, and presence of other chronic conditions.

Findings: The self-reported compliance levels among participants range from medium to high, with a mean score 3.19 (SD = 0.62, range = 1-5). No significant differences were found between men and women in compliance (t = -1.14, p = 0.127). However, significant differences in identity-related stigma were noted, with women reporting higher levels of self-stigma compared to men (t = -1.95, p = 0.023). Men reported higher use of maladaptive coping strategies (t = 2.01, p = 0.023). Negative illness representations predicted lower compliance. Contrary to the hypothesis, self-stigma related to identity concerns was associated with higher compliance, while stigma related to blame and judgment correlated with lower adaptive coping strategies. Maladaptive coping strategies were linked to lower compliance, and no relationship was found between adaptive coping strategies and compliance. Participants using a combined insulin pump and sensor showed higher compliance compared to those not using this protocol.

Conclusions: This study underscores the critical role of illnessrepresentations, stigma, and coping strategies in shaping patient compliance. Interventions should focus on reducing negative illness representations and improving adaptive coping strategies to enhance compliance in T1DM patients. The findings underscore the need for gender- and culture-sensitive interventions, and the use of advanced technologies, like insulin pumps and continuous glucose monitors, which were found to predict better compliance.

Research Significance: This study is the first to examine compliance among T1DM patients aged 18 and over from the Arab population in Israel, using the Self-Regulation Model and comparing gender differences, thereby enriching both theoretical and empirical knowledge in this field. Practically, it contributes to the development of tailored interventions for Arab T1DM patients in Israel, addressing cognitive, emotional, and cultural factors influencing compliance.

Keywords: Type 1 Diabetes Mellitus (T1DM), patient compliance, illness representations, stigma, coping strategies, Arab population, gender differences, self-care, insulin pump, continuous glucose monitors.