Disability and Health Journal 7 (2014) 119e123 www.disabilityandhealthjnl.com
Brief Report
Self-esteem as mediator and moderator of the relationship between stigma perception and social alienation of Chinese adults with disability Lin Zhang, Ph.D.a,*, Wentao Li, M.S.b, Binbin Liu, M.S.c, and Wenlan Xie, M.S.a b
a School of Psychology, Ningbo University, Jiangbei District, Ningbo, China Faculty of Liberal Arts and Communication, Ningbo University, Ningbo, China c Graduate School, Ningbo University, Ningbo, China
Abstract Background: Several studies show the relationship between self-esteem and stigma perception and also between self-esteem and social alienation, but none sufficiently analyze the relationship between stigma perception and social alienation of people with disability. Objective/hypothesis: The primary aim of this paper is to investigate the mediator and moderator effects of self-esteem on the relationship between stigma perception and social alienation of people with disability. Methods: The participants were 129 adults with disability (80 males and 49 females) from eight communities in China. Data was collected by using the stigma perception scale, self-esteem scale, social avoidance scale, social anxiety subscale of the selfconsciousness scale, and loneliness scale. Each item is rated on a 5-point scale (1 5 ‘‘strongly disagree’’ to 5 5 ‘‘strongly agree’’). Results: Stigma perception was positively correlated with social avoidance ( p ! 0.001), social anxiety ( p ! 0.001), and loneliness ( p ! 0.001). Self-esteem was inversely correlated with social avoidance ( p ! 0.001), social anxiety ( p ! 0.001), loneliness ( p ! 0.001), and stigma perception ( p ! 0.001). Conclusions: Self-esteem partially mediated the relationship between stigma perception and social avoidance, social anxiety and loneliness. Moreover, self-esteem moderated the relationship between stigma perception and social avoidance, but not on social anxiety and loneliness. Ó 2014 Elsevier Inc. All rights reserved. Keywords: Chinese adults with disability; Stigma perception; Social alienation; Self-esteem
In recent years, the objective living environment of people with disability has been greatly improved in China, such as income, education, employment and disabled facilities, but participation in social activity of person with disability has never been improved. According to the report of the 2010 national disability status and well-off process monitoring, the proportion of people with disability participating in community culture and sports is still low, with the proportion of frequently participating around 5% and the proportion of occasionally participating less than 30%. Nearly two thirds of them hardly went out of the house and into society. So, the social alienation trend of people with disability is obvious in China. Authors have no conflicts of interest to declare. This study was supported by grants from the Program for National Social Science Fund (12BSH055), Philosophy and Social Science, Zhejiang Province (11ZJQN015YB) and sponsored by the K.C. Wong Magna Fund at Ningbo University. * Corresponding author. Fax: þ86 (0)57487609125. E-mail address:
[email protected] or
[email protected] (L. Zhang). 1936-6574/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2013.07.004
Social alienation (SA) is a psychological and behavioral expression of automatic estrangement and isolation that comes from the potential effect of individual social action based on negative attitude due to lack of overall cognition.1 SA contains an objective and a subjective evaluation. The objective evaluation of SA is social avoidance, which is an objective reflection of social interaction.2 The subjective evaluation of SA is social anxiety and loneliness, which is the subjective feeling of dissatisfaction with a low number of social contacts.3,4 Social alienation of people with disability also separates them from social groups, and marginalizes them in the peer group. As some research indicates, people with disability tend toward isolation and social avoidance resulting in the inability to establish good interpersonal relationships with others5,6 and few people are willing to make friends with them.7,8 Moreover, social alienation also leads to many psychological adaptation problems, including loneliness, anxiety and inferiority9e11 and a series of other problems, such as mental health issues9,11 and internet addiction.12,13
120
L. Zhang et al. / Disability and Health Journal 7 (2014) 119e123
Stigma perception, as an important predictive variable of social alienation14e18 is a sensitivity perception that is perceived from negative behavior or attitudes (such as injustice, injury and refusal). A reported that 62% of person with disability said they have experienced stigmatization from peers to the point that their friendships have disintegrated, and 46% from their family, resulting in behaviors such as distrust and lack of sympathy and compassion, thus increasing the likelihood of loneliness, depression and reclusion.19 Furthermore, most adults with disability said they feel a stigma and unfair treatment from others in the workplace.20,21 It is because of stigma perception, they often doubt their social skills, or even doubt their perception of self-worth,22,23 creating emotional problems like anxiety and depression.24,25 Thus, stigma perception is an important variable in social alienation research of people with disability. Self-esteem is an individual’s integrity understanding of one’s self-worth and one of the most predictive variables in social alienation research.26 In some studies, self-esteem has been found to be one of the stronger predictors of social alienation.27e29 Meanwhile, some researchers also provide evidence that there is significant correlation between stigma perception and self-esteem23,30 and stigma perception also impacts the level of individual’s depression by decreasing self-esteem16,31,32 So self-esteem of person with disability is an intermediate variable between stigma perception and social alienation. The aim of this study is to test the role of self-esteem as an intervening variable in the relationship between stigma perception and social alienation in Chinese adults with disability through two alternative models. In the mediational model, whether self-esteem functions as a mediator between stigma perception and social alienation has been examined. In light of the reciprocal relationships between self-esteem, stigma perception and social alienation that have been established by previous studies, it was predicted in the current study that as stigma perception decreases, social alienation will also decrease and self-esteem will have an indirect role in this decrease. A meta-analytical study has shown that treatment programs directed at improving self-concept lead to positive changes in different adjustment areas.33 Some studies show that self-esteem plays a moderating function between psychological distress and some psychological variables (e.g., perceived inequity, discrimination, perceived sexist events, social rejection) in both adults and youth.34e36 As mentioned before, selfesteem is strongly related to both stigma perception and social alienation in people with disability. Self-esteem may not only serve as a mediator between stigma perception and social alienation, it may also have a ‘‘buffer’’ role37 which decreases the negative effect of stigma perception on social alienation as a moderator. Therefore, in the moderational model of this study, it was predicted that the relationship between stigma perception and social alienation in the individual with disability with high self-esteem
would be smaller compared to the one with low selfesteem. In summary, the aim of this study is to examine whether self-esteem plays a moderating and mediating role in the relationship between stigma perception and social alienation in people with disability in China.
Method Participants The participants were 129 adults with disability (80 males and 49 females) from eight communities in Ningbo, a midsized city in the southern part of China. The age rang was 21e79 years (M 5 49.97, SD 5 10.97). Measures The stigma perception scale (DSPS) The DSPS16 consists of ten items. Each item is answered on a 5-point Likert type scale ranging from 1 5 strongly disagree to 5 5 strongly agree. Higher scores indicate higher levels of stigma perception. In this study, Cronbach’s alphas coefficient for the DSPS was 0.89. The social alienation scale (SAS) The social avoidance scale2 consists of fourteen items, which are rated on a 5-point Likert scale from strongly disagree to strongly agree. Higher scores indicate higher levels of social avoidance. In this study, Cronbach’s alphas coefficient for the SAS was 0.77. The social anxiety scale38 consists of six items, which are rated on a 5-point Likert scale from strongly disagree to strongly agree. Higher scores indicate higher levels of social anxiety. In this study, Cronbach’s alphas coefficient for the SAS was 0.78. The loneliness scale39 consists of eight items which are rated on a 5-point Likert scale from strongly disagree to strongly agree. Higher scores indicate higher levels of loneliness. In this study, Cronbach’s alphas coefficient for the LS was 0.90. The self-esteem scale (SES) The SES26 consists of ten items which are rated on a 5-point Likert scale from strongly disagree to strongly agree. In this study, Cronbach’s alphas coefficient for the SES was 0.79. Procedure 129 adults with disability from the eight communities were randomly selected. Self-report questionnaires were completed in the classroom after informing consent. It took approximately 25 min to complete all the instruments.
L. Zhang et al. / Disability and Health Journal 7 (2014) 119e123 Table 1 Intercorrelations and descriptive statistics of all variables in the study 1 2 3 1. 2. 3. 4. 5.
Stigma perception Self-esteem Social avoidance Social anxiety Loneliness
e 0.43*** 0.42*** 0.71*** 0.69***
e 0.47*** 0.43*** 0.47***
e 0.59*** 0.47***
4
e 0.70***
121
5
M
SD
Skewness
Kurtosis
e
2.60 3.71 2.79 2.89 2.74
0.78 0.58 0.48 0.77 0.86
0.20 0.06 0.46 0.07 0.08
0.52 0.69 1.25 0.44 0.78
Note: All correlations are significant at the 0.001 level.
Results Descriptive statistics and bivariate zero-order correlations for the measured variables are presented in Table 1. Stigma perception was positively correlated with social avoidance (0.42, p ! 0.001), social anxiety (0.71, p ! 0.001), and loneliness (0.69, p ! 0.001). Selfesteem was inversely correlated with social avoidance (0.47, p ! 0.001), social anxiety (0.43, p ! 0.001), loneliness (0.47, p ! 0.001), and stigma perception (0.43, p ! 0.001). Self-esteem as a mediator Four criteria are required to reveal a mediator effect.40 First, the predictor variable (stigma perception) must be related to the mediator variable (self-esteem). Second, the predictor variable must be related to the outcome variable (social avoidance, social anxiety and loneliness). Third, the mediator variable must be related to the outcome variable. Fourth, after controlling for the effects of the mediator on the outcome, the relation between the predictor and the outcome must be significantly decreased. To test for a mediation effect of self-esteem on the relationships between stigma perception and social avoidance (or social anxiety and loneliness), a series of three regressions were conducted. First, self-esteem was regressed on stigma perception (b 5 0.43; p ! 0.001). Stigma perception contributed a significant amount of variance to self-esteem (18.4%). Second, social avoidance (or social anxiety and loneliness) was regressed on stigma perception (b 5 0.42, 0.71, 0.69; p ! 0.001). Stigma perception explained a significant amount of variance to social avoidance (or social anxiety and loneliness) (17.9%, 50.5%, 47.4%). In the third equation, social avoidance (or social anxiety and loneliness) was simultaneously regressed on both self-esteem (b 5 0.36, p ! 0.001; b 5 0.15, 0.21, p ! 0.05) and stigma perception (b 5 0.27, 0.65, 0.60; p ! 0.001). Finally, the regression model contributed a significant amount of variance to social avoidance (or social anxiety and loneliness) (28.3%, 52.7%, 51.1%). The results of regression analyses testing mediation effects of self-esteem on the relationship between stigma perception and social avoidance (or social anxiety and loneliness) are presented in Fig. 1. As shown in Fig. 1, the beta weight when stigma perception was regressed alone on
social avoidance (or social anxiety and loneliness) was 0.42 (0.71, 0.69). The beta weight dropped from 0.42 (0.71, 0.69) to 0.27 (0.65, 0.60) when self-esteem was added into the equation. The Sobel test revealed that selfesteem significantly mediated the relationship between stigma perception and social avoidance (or social anxiety and loneliness) (Z 5 4.18, p ! 0.001; Z 5 1.59, p ! 0.05; Z 5 1.99, p ! 0.05). Full mediation obtains if the predictor variable (self-esteem) has no significant effect on the outcome variable (depression, loneliness and social avoidance) when the mediator (self-esteem) is controlled.40 Therefore, these results indicated that self-esteem only partially mediated the relationship between stigma perception and social alienation (see Fig. 1). Self-esteem as a moderator In order to test moderating effects of self-esteem on the relationships between stigma perception and social alienation, hierarchical regression procedures were performed as recommended.40 In the hierarchical regression model, the order of entry was as follows. At Step 1 and Step 2, the predictor (stigma perception) and moderator (selfesteem) variables were entered sequentially into the regression equations. At Step 3, the interactions of stigma self-esteem were added. Significant change in R2 for the interaction term indicates a significant moderator effect. The analysis showed that stigma perception (b 5 0.42, p ! 0.001) and self-esteem (b 5 0.36, p ! 0.001) predicted significantly to social avoidance. In this model, higher stigma perception and lower self-esteem were associated with greater social avoidance, and there was significant
Fig. 1. Mediation model for stigma perception, self-esteem, social avoidance, social anxiety and loneliness. *p ! 0.05; **p ! 0.01; ***p ! 0.001.
122
L. Zhang et al. / Disability and Health Journal 7 (2014) 119e123
Fig. 2. Effects of stigma perception (SC) and self-esteem on social avoidance scores.
interaction between stigma perception and self-esteem (b 5 0.17, p ! 0.05). These findings showed that selfesteem had a moderating effect on the relationship between stigma perception and social avoidance. To illustrate the stigma perception self-esteem interaction for social avoidance, we plotted the regression of social avoidance on stigma perception at high and low levels of selfesteem (see Fig. 2). We used the simple slope for the regression of social avoidance on stigma perception by using the high (one standard deviation above the mean) and low (one standard deviation below the mean) values for selfesteem.41 As Fig. 2 shows, there was a significant positive relation between stigma perception and social avoidance at high levels of self-esteem (simple slope 5 0.47, t 5 3.86, p ! 0.001). However, at low levels of selfesteem, the relation between stigma perception and social avoidance was non-significant (simple slope 5 0.08, t 5 0.68, p O 0.05). Hence, among disabled with high self-esteem, stigma perception was a significant determinant of social avoidance. In contrast, at low levels of selfesteem, stigma perception did not influence social avoidance. Discussion This study examined the mediator and moderator effects of self-esteem for the relationship between stigma perception and social alienation in Chinese adults with disability. As expected, the correlational findings of the study indicate that each component of social alienation has a relationship with self-esteem and stigma perception at a medium level of significance. These results are consistent with earlier studies reporting a relationship between social alienation and self-esteem27e29,42 and stigma perception.16,43e45 Moreover, even when gender, age, and stigma perception were controlled, it was observed that self-esteem can be a significant predictor of social alienation. This finding
supports earlier research that shows that self-esteem is one of the strongest variable predictors of social alienation. In this study, as expected, self-esteem played a mediator function partially between stigma perception and different components of social alienation. In other words, people with disability with high levels of stigma perception are likely to engage in lower self-esteem, which in turn contributed to enhanced social avoidance, social anxiety and loneliness. These results are consistent study that reported that selfesteem mediated the relationship between stigma perception, social anxiety and loneliness in migrant children.16 Selfesteem as a positive judgment and evaluation will promote an individuals’ development of satisfying relationships,46 thus it can be expected that they will feel less stigma. In this way, it can be stated that stigma perception reflects less negatively on social alienation with the help of self-esteem. Another interesting result of this study is that selfesteem moderated the influence of stigma perception on social avoidance, but not on social anxiety and loneliness. When the Chinese adults with disability reported a high level of self-esteem, those with low stigma perception reported lower scores in social avoidance than those with high stigma perception. However, there were no differences in social avoidance between high and low stigma perception groups when they were confronted by a low level of self-esteem. Based on this result, it can be stated that self-esteem only has a preventive function over the negative effects of stigma perception on social avoidance, therefore playing a ‘‘buffer’’ role.37 This surprising finding is probably due to the cultural differences between China and western countries. The present study has some limitations. The first limitation is that the study’s correlational cross-sectional nature prohibits drawing any causal relationships among the variables. Interpretation of the results of mediational analyses on cross-sectional data must always be done with caution. Future longitudinal or experimental studies will facilitate more causal evaluations. The second limitation is that humor style and self-esteem were the only potential mediators examined in the present study even though there are certainly other mediators that are likely to play an important role in the association between stigma perception and social avoidance; other variables, such as social support, can be examined. The third limitation is that the data in this study was collected only through self-report scales. The use of multiple methods for evaluation (e.g., spouse, children and peer reports) may decrease the ‘‘subjectivity’’ limitation of the findings. The fourth limitation is that the findings of the current study should be generalized only to people with disability in China. Despite the limitations, the current study substantially extended our insight into underlying mechanisms between stigma perception and social avoidance. The employment of people with disability provided meaningful evidence for external validity of the self-esteem mediated model in China. In addition, the significant path from stigma perception
L. Zhang et al. / Disability and Health Journal 7 (2014) 119e123
through low self-esteem to social avoidance sheds light on the underlying mechanisms of the vicious cycle that leads stigma perception individuals to suffer from social avoidance. References 1. Qi YZ. Discussion on the social alienation. J Chongqing Tech Bus Univ (Soc Sci Ed). 2010;27:82e86. 2. Watson D, Friend R. Measurement of social-evaluative anxiety. J Consulting Clin Psychol. 1969;4:448e457. 3. Cattan M, White M. Health Promotion Interventions Targeting Social Isolation and Loneliness. Paper Presented at the Health Promotion for Elderly People: a Research into Ageing Workshop. London: London School of Hygiene and Tropical Medicine; 1999. 4. Hall M, Havens B. Ageing in Manitoba Study. Winnipeg, Manitoba: Department of Community Health Sciences, University of Manitoba; 1999. 5. Sharanjit U. Impact of the timing, type and severity of disability on the subjective well-being of individuals with disabilities. Soc Sci Med. 2006;63:525e539. 6. Shapiro DR, Martin JJ. Athletic identity, affects, and peer relations in youth athletes with physical disabilities. Disabil Health J. 2010;3: 79e85. 7. Frostad P, Pijl SJ. Does being friendly help in making friends? The relation between the social position and social skills of pupils with special needs in mainstream education. Eur J Spec Needs Educ. 2006;22:15e30. 8. Ge P, Zhang ML. Research on the relationship among interpersonal disturbances, self-esteem and social support in deaf undergraduates. China J Health Psychol. 2010;18:356e358. 9. Fitzgerald B, Ring H. Epilepsy, mental health, adults with learning disability reviewing the evidence. Psychiatry. 2009;11:422e424. 10. Zhang XL, Li XZ, Wang ZS, et al. Analysis of mental health of 163 disabled college students. Chin J Sch Health. 2010;31:608e609. 11. Kariuki M, Honey A, Emerson E, et al. Mental health trajectories of young people after disability onset. Disabil Health J. 2011;4:91e101. 12. Zhang KD, Li JW, Meng Y. A study on internet addiction among medical college students with limb disabled. China J Health Psychol. 2007;15:778e790. 13. Mari CD. An overview of the internet of things for people with disabilities. J Netw Comput Appl. 2012;35:584e596. 14. Grossman JM, Belle L. Discrimination distress among Chinese American adolescents. J Youth Adolesc. 2008;37:1e11. 15. Fang XY, Fan XH, Liu Y. Perceived discrimination and loneliness: moderating effects of coping style among migrant children. Psychol Dev Educ. 2008;24:93e99. 16. Lin XY, Fang XY, Liu Y, et al. The effect mechanism of stigma perception on mental health among migrant children in Beijing. Acta Psychologica Sinica. 2009;41:967e979. 17. Pascoe EA, Smart Richman L. Perceived discrimination and health: a meta-analytic review. Psychol Bull. 2009;135(4):531e554. 18. Liu X, Shen JL. Chinese migrant children’s perceived discrimination and its relation to self-esteem. Psychol Sci. 2010;3:695e697. 19. Tally M. Being treated differently: stigma experiences with family, peers, and school staff among adolescents with mental health disorders. Soc Sci Med. 2010;7:985e993. 20. Beatty J, Kirby S. Beyond the legal environment: how stigma influences invisible identity groups in the workplace. Employ Responsib Rights J. 2006;1:29. 21. Moore ME, Konrad AM, Yang Y, et al. The vocational well-being of workers with childhood onset of disability: life satisfaction and perceived workplace discrimination. J Vocat Behav. 2011;3:681e698. 22. Miyahara M, Piek J. Self-esteem of children and adolescents with physical disabilities: quantitative evidence from meta-analysis. J Dev Phys Disabil. 2006;3:219e234.
123
23. Alecia MS. Anticipating evaluative social interactions involving persons. Rehabil Psychol. 2011;3:231e242. 24. Finch BK, Kolody B. Perceived discrimination and depression among Mexican-origin adults in California. Health Soc Behav. 2000;21: 295e313. 25. Foster MD. Positive and negative responses to personal discrimination: does coping make a difference? J Soc Psychol. 2000;1: 93e107. 26. Rosenberg M. Society and the Adolescent Self-image. Princeton, NJ: Princeton University Press; 1965. 27. Boelen PA, Reijntjes A. Intolerance of uncertainty and social anxiety. J Anxiety Disord. 2009;23:130e135. 28. Rasmussen MK, Pidgeon AM. The direct and indirect benefits of dispositional mindfulness on self-esteem and social anxiety. Anxiety Stress Coping. 2011;24:227e233. 29. De Jong PJ, Sportel BE, De Hullu E, et al. Co-occurrence of social anxiety and depression symptoms in adolescence: differential links with implicit and explicit self-esteem? Psychol Med. 2012;42: 475e484. 30. Ross MGN, Deborah W, Jill L, et al. Parsing the relationship of stigma and insight to psychological well-being in psychotic disorders. Schizophr Res. 2011;3:3e7. 31. Corning AF. Self-esteem as a moderator between perceived discrimination and psychological distress among women. J Couns Psychol. 2002;49:117e126. 32. Diaz RM, Ayala G, Bern E. The impact of ho-mophobia, poverty, and racism on the mental health of gay and bisexual Latino men. Public Health. 2001;91:927e932. 33. Haney P, Durlak JA. Changing self-esteem in children and adolescents: a meta-analytic review. J Clin Child Psychol. 1998;27: 423e433. 34. Longmore MA, Demaris A. Perceived inequity and depression in intimate relationships: the moderating effect of self-esteem. Soc Psychol Q. 1997;60:172e184. 35. Moradi B, Subich LM. Examining the moderating role of self-esteem in the link between experiences of perceived sexist events and psychological distress. J Couns Psychol. 2004;51:50e56. 36. VanDellen M, Knowles ML, Krusemark E, et al. Trait self-esteem moderates decreases in self-control following rejection: an information-processing account. Eur J Personal. 2012;26:123e132. 37. Frazier PA, Tix AP, Barron KE. Testing moderator and mediator effects in counseling psychology research. J Couns Psychol. 2004;51:115e134. 38. Fenigstein A, Scheier M, Buss AH. Public and private selfconsciousness: assessment and theory. J Consult Clin Psychol. 1975;43:522e527. 39. Russell D, Peplau LA, Ferguson ML. Developing a measure of loneliness. J Pers Assess. 1987;42:290e294. 40. Baron RM, Kenny DA. The moderatoremediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51:1173e1182. 41. Aiken L, West SG. Multiple Regression: Testing and Interpreting Interactions. Newbury Park, CA, USA: Sage; 1991. 42. Charles RG, Susan B. Social avoidance and distress as a predictor of perceived locus of control and level of self-esteem. J Clin Psychol. 2006;38:611e613. 43. Aygun E, Berna U. Perception of stigma among patients with schizophrenia. Soc Psychiatry Psychiatr Epidemiol. 2004;39:73e77. 44. Lysaker PH, Yanos PT, Outcalt J, et al. Association of stigma, selfesteem, and symptoms with concurrent and prospective assessment of social anxiety in schizophrenia. Clin Schizophrenia Relat Psychoses. 2010;4:41e48. 45. Sanjuan P, Molero F, Fuster MJ, et al. Coping with HIV related stigma and well-being. J Happiness Stud. 2012;10:1007e1021. 46. Dekovic M, Meeus M. Peer relations in adolescence: effects of parenting and adolescents’ self-concept. J Adolesc. 1997;20:163e176.