Stigma Framework Research Articles

Stigma and fear during the COVID-19 pandemic: a qualitative study on the perceptions of healthcare workers in Canada and Singapore.

We sought to explore healthcare providers (HCPs)' perceptions of and experiences with stigma during the COVID-19 pandemic in Canada and Singapore. We conducted a qualitative study (May 2020-February 2021) with HCPs in Canada and Singapore and developed a semi-structured interview guide rooted in the Health Stigma and Discrimination Framework (HSDF). We recruited participants online and through word of mouth via newsletters, blogs and social media. Participants were eligible to participate if they worked as a healthcare provider in Singapore or Canada during COVID-19. Following participant consent, data were recorded, transcribed verbatim, and coded using a framework approach. Coded data were charted into a framework matrix and used to compare themes in each country. We conducted 51 interviews (23 in Canada; 28 in Singapore). HCPs perceived that patient fears coupled with mistrust of the health system impacted health behaviors. HCPs reported discrimination and stigmatization of population subsets. In Singapore, this included Chinese tourists and migrant workers and in Canada, this included people of Chinese ethnicity and people experiencing homelessness. This stigma was often attributed to pre-existing prejudices including perceptions that these populations were at increased risk of COVID-19 or not adhering to public health recommendations. HCPs feared spreading COVID-19 to family, peers and patients, often resulting in participants choosing to isolate from social circles. HCPs in both countries experienced occupation-based stigma, including stigma related to public health practices (masking, testing); in Canada, this intersected with race-based prejudice for participants of Chinese ethnicity. HCPs in both samples witnessed and experienced stigmatizing behavior; some participants also experienced discrimination. Secondary stigma related to occupation was experienced by HCPs during COVID-19. HCPs experienced intersecting stigma based on race/ethnicity and observed stigmatization of marginalized patient populations. Most themes were consistent across Canada and Singapore. Strategies to mitigate COVID-19 related stigma toward HCPs and at-risk patient populations are warranted.

Women living with HIV face intersectional stigma from infection, domestic violence, and other marginalized identities: a qualitative study in West Bengal, India

BackgroundWomen living with HIV bear a disproportionate burden of stigma, especially in countries where gender discrimination is more common. A result is widespread domestic violence against women. This violence is itself stigmatized, but the intersectional stigma of HIV and domestic violence has not been well studied. Our work aimed to fill this research gap by exploring how domestic violence and HIV stigma intersect with other marginalized identities in women’s lives.MethodsSemi-structured interviews were conducted in Kolkata, India with 31 women living with HIV and 16 key informants to gain an understanding of intersecting stigmas. Interviewees discussed women’s experiences and perceptions of stigma and discrimination around HIV, domestic violence, and other marginalized identities. The coding of data was informed by an intersectional stigma framework. Thematic Network Analysis was used to group themes originating in the data into higher-order themes connecting to a global theme.ResultsThe findings presented are a qualitative self-report of violence. The three main themes developed were (1) the intersectional stigma of HIV and domestic violence amplified stigma as a whole, (2) the intersection of multiple stigmas worsens domestic violence, and (3) the stigma of HIV hides domestic violence. Specifically, HIV stigma triggered domestic violence and perpetrators reinforced HIV stigma through verbal abuse. Women with other marginalized identities, such as having daughters or being a widow, experienced substantial violence. Domestic violence stigma was worsened by HIV stigma as women hid the violence for fear of revealing their status. As a result, help-seeking from formal and informal sources decreased, which increased women’s isolation.ConclusionsThe findings shape new understandings of how intersectional stigma of HIV, domestic violence, and marginalized social identities interact to amplify stigma and related violence. Women living with HIV who have multiple marginalized identities should be prioritized for violence reduction interventions.

"It Was So Easy in a Situation That's So Hard": Structural Stigma and Telehealth Abortion.

For decades, sociological research has examined the role of stigma in contributing to health disparities, yet such research seldom grapples with the interplay between individuals and structures. There is a particular paucity of research on abortion that concurrently examines individual experiences with stigma and structural barriers. In this article, we use telehealth abortion as a case, which now accounts for one in five abortions in the United States. We conducted 30 interviews and approach the data using a structural stigma framework in tandem with conceptualizations of felt, internalized, and enacted stigma. Findings advance a sociological theory of structural abortion stigma: a combination of structural barriers, internalized beliefs, and interpersonal shame. Telehealth reduces structural barriers to abortion and mitigates internal and interpersonal experiences of stigma. The latter is achieved by the ability to avoid the traditional abortion clinic, which many interviewees view as the site where stigma is produced and experienced.

Categorizing Stigma as a Barrier to Support Following Nonfatal Overdose: A Qualitative Study

Objectives Stigma is known to be a major barrier to treatment for people who use drugs (PWUD). This study uses the Stigma and Health Discrimination Framework to analyze how different forms of stigma shape experiences in the wake of an overdose incident, and perceptions of the efficacy and utility of postoverdose interventions among a sample of PWUD in Dayton, Ohio—a location with a high overdose rate. Methods Interviews were conducted with 23 individuals who self-reported past-month illicit opioid, crack/cocaine, or methamphetamine use who had experienced or witnessed a drug overdose in the past 6 months. Interviews were recorded, transcribed, and thematically analyzed using Taguette software. Results Discrete forms of stigma were identified as barriers to postoverdose interventions intended to link PWUD with support and services to help them access treatment. Individuals identified experiences of enacted stigma through medical mistreatment, exploitation, and judgment. They identified anticipated stigma through mistrust and unsustainable treatment. Internalized stigma was identified through the effect of loss on mental health, feeling “stuck,” and the role of race on support-seeking behaviors. Experiences of structural stigma included desensitization of addiction as a disease and lack of feasible, long-term treatment options. Conclusions The results suggest that enacted, anticipated, internalized, and structural forms of stigma act as barriers to the efficacy of postoverdose outreach programs, and the initiation and sustainability of treatment. Understanding how each form of stigma adversely impacts PWUD can improve public health and clinical interventions to reduce stigma and overdose death.

The Influence of Photographic Representations on U.S. Medical Students’ Attitudes and Beliefs About Persons With Disabilities: A Qualitative Study

Phenomenon: There is a crucial need to more deeply understand the impact and etiology of bias toward persons with developmental disabilities (PWDD). A largely unstudied area of concern and possible intervention is the portrayal of PWDD in medical education. Often, medical photographs portray PWDD with obscured faces, emotionless, and posed in an undignified way. This exploratory, qualitative study aimed to explore how photo representations of PWDD influences medical students’ attitudes and beliefs toward disability. Approach: We recruited 10 medical students from a single medical school in the northeastern United States to participate in in-depth, individual semi-structured interviews via Zoom. During the interviews, we asked students to reflect on and respond to two image sets of PWDD: a standard image set, which were photos from medical textbooks, and a positive image set, which were photos from the U.S.-based disability nonprofit, Positive Exposure. Using thematic analysis underpinned by the Health Stigma and Discrimination Framework, we coded and organized the transcripts into four themes that characterized participants’ attitudes and beliefs about PWDD. Findings: The four themes we identified were as follows. Humanization vs. dehumanization: Standard imagery characteristics (e.g., black bars, unnatural posing, lack of clothing) were perceived as dehumanizing and raised concerns about consent and autonomy, whereas positive imagery characteristics (e.g., clothing, natural poses, nonclinical settings) were seen as humanizing and enhanced perceptions of agency. Quality of life: Standard imagery often led to assumptions of compromised quality of life, while positive imagery suggested a good quality of life. Discomfort vs. comfort with communication in a clinical setting: Dehumanizing portrayals increased perceived difficulty in establishing rapport, while humanizing imagery mitigated these perceived barriers. Diversity: Image sets showcasing a diverse spectrum of presentations for a given diagnosis were valued for medical education. Insights: We conclude that photographic representation of disability in medical education can influence medical students’ attitudes and beliefs about PWDD. Photographic elements can either humanize or dehumanize, with humanizing representation leading to more positive attitudes and therefore also an educational benefit. Thoughtful and inclusive visual content is needed in medical education to encourage positive attitudes and foster a more empathetic healthcare environment. Our results support future plans to further investigate how photo representation affects attitudes in a larger sample. Additionally, our study’s insights contribute to the ongoing initiative Textbook Beauty, providing guidance for the selection of photography to improve attitudes toward disabilities.

“Just Google It”—A Qualitative Study of Reproductive-Age Women's Stigmatizing Experiences When Accessing Buprenorphine for Opioid Use Disorder

IntroductionThe opioid crisis is increasingly impacting women, and access to buprenorphine to treat opioid use disorder (OUD) is limited by the number of providers authorized to dispense it. Stigma can represent an additional barrier to accessing medication for OUD. Qualitative data were analyzed from a randomized simulated patient field experiment of outpatient buprenorphine-waivered providers. ObjectivesOur primary objective was to analyze descriptions of barriers women encountered when seeking buprenorphine to treat OUD to account for differential experiences based on pregnancy status, race/ethnicity, and insurance status. Our secondary objective was to identify potential intervention strategies to improve access to medications for OUD. MethodsThe Health Stigma and Discrimination framework was applied to guide our study of barriers encountered by women seeking OUD treatment. Callers representing vocal features of white, Hispanic, and Black women and simulating ages 25–30 were randomized to represent combinations of public/private insurance and pregnant/not pregnant characteristics. Callers contacted 5,944 buprenorphine-waivered providers requesting to make an appointment to obtain medications to treat OUD. There were 15,358 free-text comments in response to the prompt “Please give an objective play-by-play of the description of what happened in this conversation.” Data were coded and analyzed using an iterative inductive-deductive approach. We consulted six community experts, women who had sought treatment for OUD, to inform our study findings and identify patient-driven solutions to address barriers. ResultsFindings revealed that experiences of interpersonal stigma were connected to systemic barriers such as stigmatizing behaviors within institutional cultures and normative practices. Key results indicate that race/ethnicity, pregnancy status, and insurance status influence experiences of stigma. For instance, Black and Hispanic callers reported experiencing race-based microaggressions, and pregnant women faced additional judgment and reduced access to treatment. Qualitative findings and community experts’ insights underscored the necessity for the adoption of anti-stigma policies and practices that facilitate easier access to medications for OUD across socioecological levels. ConclusionsThe findings demonstrate a need for multilevel interventions to improve women's access to medications for OUD.

Moving Toward Anti-Ableist Practices in Aphasia Rehabilitation and Research: A Viewpoint.

Ableism is a pervasive set of beliefs that regard nondisabled bodies and minds as ideal and necessary to live a full life. Ableism manifests for people with aphasia as stigma and discrimination based on their language ability. We assert that ableism contributes to decreased quality of life for people with aphasia and should be actively challenged and disrupted by clinicians and researchers in the field. We applied the Health Stigma and Discrimination Framework (HSDF) to outline how stigma and discrimination are perpetuated against people with aphasia on the basis of language ability and their downstream health and social consequences. We presented this framework at the Clinical Aphasiology Conference in 2023 and share themes and challenges that arose from this discussion and from our ongoing learning. Applying the HSDF to aphasia outlined potential sequelae of ableism. We identified preliminary foci of future initiatives aimed at challenging ableist beliefs and practices and means to monitor the effectiveness of such interventions. Furthermore, we draw attention to the seeming tension between anti-ableist practices and traditional language rehabilitation goals. We assert that this tension may be a catalyst for fruitful discourse on how clinicians and researchers can resist ableism while honoring the lived experiences of people with aphasia and their goals for language rehabilitation. These discussions may be facilitated by existing models in disability studies (e.g., the political/relational model). Clinicians and researchers are well positioned to challenge ableism and minimize the resultant health and social impacts for people living with aphasia. Anti-ableist practices are not antithetical to aphasia rehabilitation and can be thoughtfully integrated into rehabilitation practices and discourse.

Interdisciplinary perspectives on ‘what matters most’ in the cultural shaping of health-related stigma in Indonesia

Health-related stigma plays a significant role in the burden of various health conditions such as neglected tropical diseases and mental illnesses, and undermines successful health outcomes. Stigmatised individuals can face...

A theory-informed deep learning approach to extracting and characterizing substance use-related stigma in social media

BackgroundStigma surrounding substance use can result in severe consequences for physical and mental health. Identifying situations in which stigma occurs and characterizing its impact could be a critical step toward improving outcomes for individuals experiencing stigma. As part of a larger research project with the goal of informing the development of interventions for substance use disorder, this study leverages natural language processing methods and a theory-informed approach to identify and characterize manifestations of substance use stigma in social media data.MethodsWe harvested social media data, creating an annotated corpus of 2,214 Reddit posts from subreddits relating to substance use. We trained a set of binary classifiers; each classifier detected one of three stigma types: Internalized Stigma, Anticipated Stigma, and Enacted Stigma, from the Stigma Framework. We evaluated hybrid models that combine contextual embeddings with features derived from extant lexicons and handcrafted lexicons based on stigma theory, and assessed the performance of these models. Then, using the trained and evaluated classifiers, we performed a mixed-methods analysis to quantify the presence and type of stigma in a corpus of 161,448 unprocessed posts derived from subreddits relating to substance use.ResultsFor all stigma types, we identified hybrid models (RoBERTa combined with handcrafted stigma features) that significantly outperformed RoBERTa-only baselines. In the model’s predictions on our unseen data, we observed that Internalized Stigma was the most prevalent stigma type for alcohol and cannabis, but in the case of opioids, Anticipated Stigma was the most frequent. Feature analysis indicated that language conveying Internalized Stigma was predominantly characterized by emotional content, with a focus on shame, self-blame, and despair. In contrast, Enacted Stigma and Anticipated involved a complex interplay of emotional, social, and behavioral features.ConclusionOur main contributions are demonstrating a theory-based approach to extracting and comparing different types of stigma in a social media dataset, and employing patterns in word usage to explore and characterize its manifestations. The insights from this study highlight the need to consider the impacts of stigma differently by mechanism (internalized, anticipated, and enacted), and enhance our current understandings of how each stigma mechanism manifests within language in particular cognitive, emotional, social, and behavioral aspects.

Intersecting Stigma and the HIV Care Cascade: Qualitative Insights from Sex Workers, Men who have Sex with Men, and Transgender Women Living with HIV in Jamaica.

In Jamaica, stigma experiences of sex workers (SW), gay men and other men who have sex with men (MSM), and transgender women living with HIV remain understudied. To address this gap, we explored experiences of stigma and linkages with the HIV care cascade among key populations living with HIV in Jamaica, including cisgender women SW, MSM, and transgender women. This qualitative study involved n = 9 focus groups (FG), n = 1 FG per population living with HIV (SW, MSM, transgender women) in each of three sites (Kingston, St. Ann, Montego Bay). We also conducted key informant (KI) interviews. We applied thematic analysis informed by the Health Stigma and Discrimination (HSD) Framework. FG participants (n = 67) included SW (n = 18), MSM (n = 28), and trans women (n = 21); we interviewed n = 10 KI (n = 5 cisgender women, n = 5 cisgender men). Participant discussions revealed that stigma drivers included low HIV treatment literacy, notably misinformation about antiretroviral therapy (ART) benefits and HIV acquisition risks, and a lack of legal protection from discrimination. Stigma targets health (HIV) and intersecting social identities (sex work, LGBTQ identities, gender non-conformity, low socio-economic status). Stigma manifestations included enacted stigma in communities and families, and internalized stigma-including lateral violence. HIV care cascade impacts included reduced and/or delayed HIV care engagement and ART adherence challenges/disruptions. Participants discussed strategies to live positively with HIV, including ART adherence as stigma resistance; social support and solidarity; and accessing affirming institutional support. In addition to addressing intersecting stigma, future research and programing should bolster multi-level stigma-resistance strategies to live positively with HIV.

Examining the Interplay Between Preexposure Prophylaxis (PrEP) and Gender-Related Stigmas as Barriers for PrEP Uptake Among Transgender Women in Tijuana, Mexico: A Mixed-Methods Study.

HIV prevalence among transgender women (TW) in Tijuana, Mexico is estimated at 22%. Pre-exposure prophylaxis (PrEP) reduces the risk of HIV acquisition by > 90%, though uptake in Tijuana has been low due to limited availability. The interplay between PrEP and gender stigmas may also serve as a barrier to PrEP uptake among TW in Tijuana. Experiences of gender- and PrEP- stigmas were assessed quantitatively (Quan) among 110 HIV-negative TW and qualitatively (Qual) among 17 TW through semi-structured interviews guide by the Health Stigma and Discrimination Framework. Qual findings were triangulated with Quant data to identify factors that may support gender affirmation and reduce PrEP stigma in an explanatory sequential Quan → Qual fashion. Most participants were < 40 years of age (80%), while approximately half had at least a high school education (48.2%) and were accessing gender-affirming hormone therapy (56.4%). Mean expectations of gender stigma were greatest for endorsing negative future expectations from others (M = 17.69; possible range 0-36). PrEP stigma was prominent among those who associated negative stereotypes with PrEP users, such as poor judgment (M = 45.91; possible range 14-70) and high personal risk attributes (M = 28.61; possible range 12-60). While PrEP knowledge was low among the qualitative sample, participants identified gender-, PrEP-, and intersectional- stigmas as potential barriers to PrEP uptake. Participants suggested that resilience strategies used to combat gender stigma could also mitigate PrEP stigma. Enhancing resilience skills at the intersection of gender and PrEP stigma may reduce these barriers, facilitating greater PrEP uptake as it becomes more available in Mexico.

Stigma and discrimination faced by adolescents living with HIV and experiencing depression in Malawi

BackgroundIn Malawi, approximately 25% of adolescents living with HIV (ALWH) also suffer from depression. Not only is HIV stigma a major contributor to depression but it also adversely impacts HIV care engagement. ALWH can experience HIV stigma as stereotyping, social exclusion, low social support, and abuse, and these experiences are associated with poor mental health. Despite recognition of the deleterious effects of HIV stigma, we have limited knowledge of how stigma is experienced by ALWH with comorbid depression. Guided by the Health Stigma and Discrimination Framework, we describe stigma faced by ALWH and comorbid depression in Malawi and its implications for future interventions.MethodsAs part of a larger formative study to adapt a mental health counseling intervention, we conducted in-depth interviews, social support mapping sessions, and focus-group discussions with 25 ALWH, 4 caregivers of ALWH, 3 HIV providers, and 5 participants and 5 staff of a prior mental health counseling intervention. After analyzing the stigma codes, we used the Health Stigma and Discrimination Framework to organize the data into four key domains: drivers, manifestations, outcomes, and health and social impacts.ResultsMajor drivers of HIV stigma included fear of HIV transmission, negative effects of antiretroviral therapy (ART), association with death, inaccurate knowledge, and negative attitudes towards ALWH. The most common manifestations of HIV stigma were gossip, insults and mocking, and physical and social distancing. Decreased ART adherence and missed HIV appointments were commonly cited outcomes of HIV stigma. Broader health impacts of HIV stigma were notable for mental health comorbidities including depression, anxiety, substance use, and suicidality. Identified resilience strategies included support for HIV care engagement and psychosocial support from family and friends.ConclusionsThis study systematically describes the stigmatization process faced by ALWH and experiencing depressive symptoms in Malawi. Notably, HIV stigma continues to disrupt HIV care and detrimentally impacts mental health during adolescent development. Further studies focused specifically on stigma are needed to better characterize this process and identify additional resilience factors. Investment in stigma-reduction interventions for ALWH is needed to avert poor mental health and HIV outcomes.

“Saying ‘I'm not okay’ is extremely risky”: Postpartum mental health, delayed help‐seeking, and fears of the child welfare system among queer parents

AbstractParent mental health challenges in the postpartum and early parenthood have profound implications for parent, child, and family well‐being. Little research has focused on postpartum mental health challenges and barriers to help‐seeking among queer birthing people, including members of this community who may be particularly vulnerable to mental health difficulties, such as queer cis women partnered with men, trans/nonbinary parents, and queer parents who are young, low‐income, and/or of color. This mixed‐methods study of queer parents (n = 99), all of whom were assigned female at birth (AFAB) and gave birth to a child within the past several years, explores parents' postpartum mental health difficulties and perceived barriers to seeking help. Using a structural stigma framework, this study found that participants reported high rates of postpartum mental health difficulties (89%) and reported various barriers to seeking support including fears of discrimination and being deemed “unfit” by providers, which might lead to child welfare system involvement. Young parents and low‐income parents were particularly fearful of child welfare system contact and potential child removal. Factors that encouraged help‐seeking (e.g., desire to be a good parent; partner pressure to seek help) and implications for family practitioners are discussed.

Intersectional Structural Stigma: A Qualitative Study With Persons Experiencing Homelessness in the Southwest United States.

This study explored the manifestations of intersectional structural stigma and stigma-reducing strategies in the context of health among a diverse group of persons experiencing homelessness in the southwest United States. Purposive sampling was used to recruit youth (ages 12-17), young adults (ages 18-24), adults (ages 25 years old or older), women with children, veterans, and males over 60 years old who self-identified as homeless. Grounded theory was applied, and thematic analysis was conducted using data collected from seven focus groups (n = 76 participants). A model of intersectional stigma was adapted from the Health Stigma and Discrimination Framework. This adaptation depicts pathways for addressing intersectional stigmatization experienced by individuals with multiple intersecting identities across the interpersonal, organization, and community levels not explicitly addressed in the Health Stigma and Discrimination Framework. At the interpersonal level, participants indicated they experienced stigmatizing behaviors and practices by service providers due primarily to their identities related to economic or unhoused statuses, gender, age, and mental health. Facilitators of intersectional stigma were identified through organization practices and processes. Multiple stigmatized identities due to social beliefs also facilitated stigmatization at the community level. Health outcomes influenced by stigmatization were also identified. Despite the stigmatization they experienced, participants discussed stigma-reducing strategies related to community assets, medical care, and destigmatizing practices by service providers.

Exploring pregnancy-related stigma experiences among adolescents in rural Uganda.

Pregnant adolescents face multiple adverse experiences that vary by context due to pregnancy-related stigma. We explored experiences of pregnancy-related stigma and psychosocial issues among adolescents living in rural eastern Uganda. We conducted in-depth semi-structured interviews with 15 adolescents (15-19 years old) who were pregnant (>3 months) or had recently given birth (<3 months) at Tororo District Hospital in Uganda. All interviews were translated from Dhopadhola to English. Thematic analysis was conducted to identify major themes, which were interpreted using the Health Stigma and Discrimination Framework. Six key themes were identified and were organized under the Health Stigma and Discrimination Framework. Social and gender norms for adolescent women and their lack of autonomy were identified as drivers and facilitators of pregnancy-related stigma. Results show how stigma is experienced by adolescents through the lack of social support, multiple forms of abuse, and negative judgement. Such manifested stigma negatively impacted their psychosocial wellbeing and resulted in limited access to socioeconomic resources and educational opportunities. This study acknowledges the multilevel nature of pregnancy-related stigma among adolescents in the context of existing policy and programming. Recognizing the impact of pregnancy-related stigma on the health and wellbeing of adolescent girls necessitates prioritizing comprehensive stigma reduction interventions that address main drivers and facilitators, and that are rooted in the communities to harness support.

Stigma in Pediatric Cancer: An Exploratory Study of Osteosarcoma and Retinoblastoma in Guatemala, Jordan, and Zimbabwe.

Stigma is an understudied barrier to health care acceptance in pediatric oncology. We sought to explore the stigma experience, including its impact on cancer treatment decision making, and identify strategies to mitigate stigma for patients with osteosarcoma and retinoblastoma in Guatemala, Jordan, and Zimbabwe. Participants included caregivers, adolescent patients (age 12-19 years), and health care clinicians. A semistructured interview guide based on The Health Stigma and Discrimination Framework (HSDF) was adapted for use at each site. Interviews were conducted in English, Spanish, Arabic, or Shona, audio-recorded, translated, and transcribed. Thematic analysis focused on stigma practices, experiences, outcomes, drivers, mitigators, and interventions. We conducted 56 interviews (28 caregivers, 19 health care clinicians, nine patients; 20 in Guatemala, 21 in Jordan, 15 in Zimbabwe). Major themes were organized into categories used to adapt the HSDF to global pediatric cancer care. Themes were described similarly across all sites, ages, and diagnoses, with specific cultural nuances noted. Pediatric cancer stigma was depicted as an isolating and emotional experience beginning at diagnosis and including internalized and associative stigma. Stigma affected decision making and contributed to negative outcomes including delayed diagnosis, treatment abandonment, regret, and psychosocial fragility. Overcoming stigma led to positive outcomes including resilience, treatment adherence, pride, and advocacy. Identified stigma drivers and mitigators were linked to potential interventions. Participants describe a shared stigma experience that transcends geography, cultural context, age, and diagnosis. Stigma manifestations have the potential to impact medical decision making and affect long-term psychological outcomes. Stigma assessment tools and interventions aimed at stigma mitigation including educational initiatives and support groups specific to pediatric cancer should be the focus of future research.

Expanding access to healthcare for people who use drugs and sex workers: hepatitis C elimination implications from a qualitative study of healthcare experiences in British Columbia, Canada

BackgroundHepatitis C virus (HCV) is a major health threat in Canada. In British Columbia (BC) province, 1.6% of the population had been exposed to HCV by 2012. Prevalence and incidence of HCV are very high in populations of people who use drugs (PWUD) and sex workers (SW), who may experience unique barriers to healthcare. Consequently, they are less likely to be treated for HCV. Overcoming these barriers is critical for HCV elimination. This research sought to explore the healthcare experiences of PWUD and SW and how these experiences impact their willingness to engage in healthcare in the future, including HCV care.MethodsInterpretive Description guided this qualitative study of healthcare experiences in BC, underpinned by the Health Stigma and Discrimination framework. The study team included people with living/lived experience of drug use, sex work, and HCV. Twenty-five participants completed in-depth semi-structured interviews on their previous healthcare and HCV-related experiences. Thematic analysis was used to identify common themes.ResultsThree major themes were identified in our analysis. First, participants reported common experiences of delay and refusal of care by healthcare providers, with many negative healthcare encounters perceived as rooted in institutional culture reflecting societal stigma. Second, participants discussed their choice to engage in or avoid healthcare. Many avoided all but emergency care following negative experiences in any kind of healthcare. Third, participants described the roles of respect, stigma, dignity, fear, and trust in communication in healthcare relationships.ConclusionsHealthcare experiences shared by participants pointed to ways that better understanding and communication by healthcare providers could support positive change in healthcare encounters of PWUD and SW, who are at high risk of HCV infection. More positive healthcare encounters could lead to increased healthcare engagement which is essential for HCV elimination.

Medical student perceptions of mental illness: a cross-sectional transnational study in two medical schools

BackgroundDespite shifting global attitudes, mental illness remains highly stigmatised amongst practicing doctors. This has wider implications on doctors’ training to care for patients with mental illness. There is need for exploration of the presence and mitigation of stigma in early medical education to prevent such attitudes propagating into clinical practice. Thus, this study explores whether stigmatising attitudes are detectable amongst medical students in London and Singapore and examines whether they are ameliorated by specific curricular and welfare features of formal medical education, utilising the Mental Illness Stigma Framework (MISF).MethodsA mixed-methods approach was adopted. Medical students at Imperial College London (UK; n = 211) and Nanyang Technological University (Singapore; n = 141) completed a validated scale (the OMS-HC-15) to assess attitudes towards mental illness. Semi-structured interviews were conducted (Imperial: n = 12, NTU: n = 8) until theoretical saturation was reached. Quantitative data were analysed descriptively and comparatively using SPSS and interview data subjected to inductive thematic analysis.ResultsTotal OMS-HC-15 scores ranged from 19–51 for Imperial (n = 211) and 16–53 for NTU (n = 141). No significant differences in overall stigma scores were found between the two schools (p = 0.24), nor when comparing year groups within each school. Four themes were identified across interview data: student perceptions, impacts of medical school culture, university support, and curricular impacts on mental illness perceptions. Themes allowed identification of aspects of medical school that were well-received and warranted further emphasis by students, alongside areas for improvement.ConclusionMental health stigma was identified in two medical schools, with differing cultures. Mean stigma scores obtained were comparable between both UK and Singaporean medical students. Nuanced differences were identified via subgroup analysis, and the MISF identified both shared and country-specific drivers for this stigma across the qualitative data. Actionable recommendations to mitigate this were hypothesised. Curricular improvements such as earlier psychiatric teaching and sharing of personal stories may improve future stigma scores as students’ progress through the course. Specific welfare-based changes to formal support systems were also deemed to be beneficial by students. The impacts of welfare and curricular redesign in relation to societal influence on students’ attitudes warrants further investigation, as does medical students’ self-stigma.

Association Between Clinical Encounter Frequency and HIV-Related Stigma Among Newly-Diagnosed People Living with HIV in Rwanda.

HIV-related stigma in healthcare settings remains a key barrier to engaging people living with HIV (PLHIV) in care. This study investigated the association between clinical encounter frequency and HIV-related anticipated, enacted, and internalized stigma among newly-diagnosed PLHIV in Rwanda. From October 2020 to May 2022, we collected data from adult PLHIV on antiretroviral therapy (ART) in Kigali, Rwanda who were participating in a randomized, controlled trial testing early entry into differentiated care at 6 months after ART initiation. We measured anticipated HIV stigma with five-point Likert HIV Stigma Framework measures, enacted stigma with the four-point Likert HIV/AIDS Stigma Instrument, and internalized stigma with the four-point Likert HIV/AIDS Stigma Instrument. We used multivariable linear regression to test the associations between clinical encounter frequency (average inter-visit interval ≥ 50 days vs. < 50 days) and change in mean anticipated, enacted and internalized HIV stigma over the first 12 months in care. Among 93 individuals enrolled, 76 had complete data on encounter frequency and stigma measurements and were included in the present analysis. Mean internalized stigma scores of all participants decreased over the first 12 months in care. Anticipated and enacted stigma scores were low and did not change significantly over time. There was no association between encounter frequency and change in internalized stigma. In this pilot study of newly-diagnosed Rwandan PLHIV with relatively low levels of HIV-related stigma, clinical encounter frequency was not associated with change in stigma. Additional research in diverse settings and with larger samples is necessary to further explore this relationship.

Exploring perceptions and experiences of stigma in Canada during the COVID-19 pandemic: a qualitative study

BackgroundThe COVID-19 pandemic fueled stigmatization and discrimination, particularly towards individuals of Chinese or East Asian ethnicity. We conducted interviews with members of the public in Canada in order to describe and understand stigma perceptions and experiences during the COVID-19 pandemic.MethodsWe used a phenomenological approach to describe stigma experiences of Canadian residents during the COVID-19 pandemic and compared the stigma perceptions and experiences of East Asian and non-East Asian individuals. Participants were invited to take part in a single, semi-structured interview. The interview guide was rooted in the Health Stigma and Discrimination Framework (HSDF). Interviews were conducted in English, Mandarin, and Cantonese. Following participant consent, interviews were audio recorded and transcribed verbatim. Data were double coded and analyzed using qualitative content analysis guided by a framework approach.ResultsA total of 55 interviews were conducted between May and December 2020. Fifty-five percent of the sample identified as East Asian, 67.3% identified as women, and mean age was 52 years (range 20–76). Fear of infection, fear of social and economic ramifications, and blame for COVID-19 were reported drivers of stigma. Participants described preexisting perceptions on cultural norms and media influence as facilitators of stigma that propagated harmful stereotypes, particularly against Chinese and East Asian individuals. Participants observed or experienced stigmatization towards place of residence, race/ethnicity, culture, language, occupation, and age. Stigma manifestations present in the public and media had direct negative impacts on East Asian, particularly Chinese, participants, regardless of whether or not they personally experienced discrimination.ConclusionsWe used the HSDF as a rooting framework to describe perceptions and impact of stigma, particularly as they related to race/ethnicity-based stigmatization in Canada. Participants reported a number of drivers and facilitators of stigma that impacted perceptions and experiences. These findings should be used to develop sustained strategies to mitigate stigma during public health emergencies or other major crises.