reduction of stigma prejudice discrimination and inequalities essay

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• Published: 13 April 2008

Reducing stigma and discrimination: Candidate interventions

• Graham Thornicroft 1 ,
• Elaine Brohan 1 ,
• Aliya Kassam 1 &
• Elanor Lewis-Holmes 1  

International Journal of Mental Health Systems volume  2 , Article number:  3 ( 2008 ) Cite this article

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This paper proposes that stigma in relation to people with mental illness can be understood as a combination of problems of knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination). From a literature review, a series of candidate interventions are identified which may be effective in reducing stigmatisation and discrimination at the following levels: individuals with mental illness and their family members; the workplace; and local, national and international. The strongest evidence for effective interventions at present is for (i) direct social contact with people with mental illness at the individual level, and (ii) social marketing at the population level.

Introduction

Widespread discrimination adds to the disability of people with mental illness [ 1 – 4 ]. The basic problem is this: many people with mental illness are subjected to systematic disadvantages in most areas of their lives [ 5 , 6 ]. These forms of social exclusion occur at home, at work, in personal life, in social activities, in healthcare and in the media [ 7 , 8 ].

From stigma to ignorance, prejudice and discrimination

What is stigma? The concept of stigma is necessary to develop an understanding of experiences of social exclusion, but it is not sufficient to grasp the whole picture, nor to identify what practical steps need to be taken to promote social inclusion. Stigma consists of three related problems:

The problem of knowledge: Ignorance

The problem of attitudes: Prejudice

The problem of behaviour: Discrimination

At a time when there is an unprecedented volume of information in the public domain, the level of accurate knowledge about mental illnesses (sometimes called 'mental health literacy') is meagre [ 9 ]. A population survey in England, for example, found that most people (55%) believe that the statement 'someone who cannot be held responsible for his or her own actions' describes a person who is mentally ill [ 10 ]. Most (63%) thought that fewer than 10% of the population would experience a mental illness at some time in their lives. This ignorance needs to be redressed by conveying more factual knowledge to the general public and also to specific groups such as teenagers, including useful information such as how to recognise the features of mental illness and where to get help [ 11 ].

Fear, anxiety and avoidance are common feelings both for people who do not have mental illness (when reacting to those who have) and for people with mental illness who anticipate rejection and discrimination and therefore impose upon themselves a form of 'self-stigma' [ 4 ]. Although the term 'prejudice' is used to refer to many social groups that experience disadvantage, for example minority ethnic groups, it is employed rarely in relation to people with mental illness. The reactions of a host majority to act with prejudice in rejecting a minority group usually involve not just negative thoughts but also emotions such as anxiety, anger, resentment, hostility, distaste or disgust. Prejudice may more strongly predict discrimination than do stereotypes. A recent study of terms used for mental illness by 14 year old school students in England, for example, found that they used 250 words and phrases, none of which are positive [ 12 ].

Discrimination

The scientific evidence and the strong message from service users and their advocates indicate that discrimination blights the lives of many people with mental illness, making marriage, childcare, work and a normal social life much more difficult. Actions are needed to specifically redress the social exclusion of people with mental illness and to use the legal measures intended to support all disabled people for physical and mental disabilities on the basis of parity [ 13 ]. The evidence from scientific enquiry and consultation with service users is unequivocal: discrimination means that it is harder for people with a mental illness to marry, have children, work or have a social life. This crippling social exclusion needs to be actively addressed. Laws already exist to ensure equality for all people with disabilities.

Action to support people with mental illness

Empowerment has been described as the opposite of self-stigmatisation [ 14 ]. Policy makers can provide specific financial support for ways in which individuals with mental illness can empower themselves or be empowered. Such specific support might include:

Promoting participation in formulating care plans and crisis plans for people with mental illness.

Providing cognitive-behavioural therapy for people with mental illness to reverse negative self-stigma.

Running regular assessments of consumer satisfaction with services.

Creating user-led and user-run services.

Developing peer-support worker roles in mainstream mental health care.

Encouraging employers to give positive credit for experience of mental illness

Enabling people with mental illness to take part in treatment and service evaluation and research.

Action to support people with mental illness at work

For some people with mental illness, allowance needs to be made at work for their personal requirements. In parallel with the modifications made for people with physical disabilities, people with mental illness-related disabilities may need what are called 'reasonable adjustments' in relation to the anti-discrimination laws. In practice this can include the following measures:

Having a quieter work place with fewer distractions for people with concentration problems, rather than, for example, a noisy open plan office, as well as a rest area for breaks.

Giving more or more frequent supervision than usual to give feedback and guidance on job performance.

Allowing a person to use headphones to block out distracting noise.

Creating flexibility in work hours so that they can attend their healthcare appointments or work when not impaired by medication.

Funding an external job coach for counselling and support and to mediate between employee and employer.

Providing a buddy/mentor scheme to provide on-site orientation and assistance.

Writing clear personal specifications, job descriptions and task assignments to assist people who find ambiguity or uncertainty hard to cope with.

Making contract modifications to specifically allow whatever sickness leave is required by people likely to become unwell for prolonged periods.

Providing a more gradual induction phase, for example with more time to complete tasks, for those who return to work after a prolonged absence or who may have some cognitive impairment.

Improving disability awareness in the workplace to reduce stigma and to underpin all other accommodations.

Reallocating marginal job functions that are disturbing to an individual.

Allowing use of accrued paid and unpaid leave for periods of illness.

Further, community bodies need to act to promote the social inclusion of people with mental illness. The following initiatives would address discrimination in the workplace and misinformation about mental health issues:

Employers' federations need to inform employers of their legal obligations under existing disability laws regarding people with mental illness.

Employers in the health and social care sector, when recruiting, need to make explicit that a history of mental illness is a valuable attribute for many roles.

Mental health services need to work with employers and business confederations to ensure that reasonable accommodations and adjustments in the workplace are made for people with mental illness.

The education, health and police authorities need to provide well evaluated interventions to increase integration with, and understanding of, people with mental illness to targeted groups such as schoolchildren, police and healthcare staff.

Professional training and accreditation organisations need to ensure that mental health practitioners are fully aware of the actual recovery rates for mental illnesses.

Actions needed at the local level

In local communities or health and social care economies initiatives are needed to promote social inclusion of people with mental illness. These are outlined in Table 1 .

Actions needed at the national level

In national policy a series of changes is necessary that spans government ministries, the non-government and independent sector and service user and professional groups. This is a vision of a long-term attack upon individual and systemic/structural discrimination [ 6 ] through a co-ordinated, multi-sectoral programme of action to promote the social inclusion of people with mental illness. Further social marketing approaches, the adaptation of advertising methods for a social good rather than for the consumptions of a commodity, are increasingly often being used [ 15 – 17 ].

In terms of change needed in mental health systems, several elements are necessary. An example is the development of psychological services designed to support people in or seeking work. Many people with mental illness experience demoralisation, reduced self-esteem, loss of confidence, and sometimes depression [ 18 – 22 ]. It is therefore likely that support programmes assisting people with mental illness to gain employment will need to assess whether structured psychological treatment is also needed [ 23 – 25 ]. Second, mental health staff may increasingly see the need to widen their remit from direct treatment provision to also intervening for local populations. Mental health awareness campaigns toward local programmes can be targeted to specific groups [ 26 – 28 ]. In the anti-stigma network of the World Psychiatric Association (called 'Open the Doors'), for example, such interventions have most often been applied to medical staff, journalists, school children, police, employers and church leaders [ 29 – 33 ].

Another key target group is healthcare professionals. Consumers surprisingly often relate that their experiences of general healthcare and mental healthcare staff reveal levels of ignorance, prejudice and discrimination that they find deeply distressing. This has been confirmed by studies in Australia, Brazil, Canada, Croatia, England, Malaysia, Spain and Turkey [ 34 – 42 ]. Based on the principle 'catch them young', several programmes have given anti-stigma interventions to medical students [ 39 , 43 – 46 ]. As is usual in the field of stigma and discrimination, there is more research describing stigma than assessing which interventions are effective. In Japan, one study found that the traditional medical curriculum led to mixed results: students became more accepting of mentally ill people and mental health services, and more optimistic about the outlook with treatment, but there was no impact on their views about how far people with mental illness should have their human rights fully observed [ 47 ]. Positive changes in all of these domains were achieved with a one-hour supplementary educational programme [ 48 ].

Interestingly, it seems that psychiatrists may not be in the best position to lead such educational programmes. Studies in Switzerland found no overall differences between the general public and psychiatrists in terms of social distance to mentally ill people [ 49 ]. Psychiatry itself tries to walk the narrow tightrope between the physical/pharmacological and psychological/social poles [ 50 ]. Clinicians who keep contact with people who are unwell, and who selectively stop seeing people who have recovered, may therefore develop a pessimistic view of the outlook for people with mental illnesses [ 51 ]. On balance, there is mixed evidence about whether psychiatrists can be seen as stigmatisers or destigmatisers [ 52 ]. Mental health nurses have also been found to have both more and less favourable views about people with mental illness than the general public [ 36 ]. Interestingly, nurses, like the general population, tend to be more favourable if they have a friend who is mentally ill, i.e. if there is a perceived similarity and equality with the person affected [ 53 ].

What, then, should mental health staff do? Direct involvement in the media is a vital route that professionals can use more often, with proper preparation and training. They also need to set their own house in order by promoting information within their training curricula, continuing professional development (continuing medical education) and relicensing/revalidation procedures which ensures that they have accurate information, for example, on recovery [ 54 ].

Further, practitioners need in future to pay greater attention to what consumers and family members say about their experiences of discrimination, for example in relation to work or housing. Staff can also work directly with consumers to combat social exclusion, for example by opposing repressive or regressive mental health laws [ 55 ]. Third, it is clear that consumer groups increasingly seek to change to the terms of engagement between mental health professionals and consumers, and to move from paternalism to negotiation [ 14 ]. Vehicles to support shared decision-making include: crisis plans [ 56 ] which seem able to reduce the frequency of compulsory treatment [ 57 ], advance directives [ 58 ], shared care agreements [ 59 ] and consumer-held records [ 60 ]. The key fact is that many consumers want direct participation in their own care plans [ 61 ].

Going into the public advocacy domain, staff in mental health systems may well develop in future a direct campaigning role. A practical approach is for local and national agencies to set aside their differences and to find common cause. In various areas, such co-ordinating groups are called forums, peak bodies, alliances or consortia. What they have in common is a recognition that what they can achieve together, in political terms, is greater that their individual impact. Core issues able to unite such coalitions are likely to include parity in funding, the use of disability discrimination laws for people with mental illness-related disabilities, and the recognition of international human rights conventions in practice [ 62 – 65 ]. The actions needed at a national level are summarised in Table 2 .

Action at the international level

What action is necessary at the international level? Such contributions, so far removed from the everyday lives of people, may be hardly noticeable unless they are very sharply focussed and coherent. Setting international standards for national polices could be one useful intervention. For example the World Health Organisation (WHO) has published standards to guide countries in producing and revising mental health laws [ 66 ]. The standards cover advice on:

access to care

confidentiality

assessments of competence and capacity

involuntary treatment

physical treatments

privacy of communications

appeals against detention

review procedures for compulsory detention [ 66 ]

At present, 25% of countries worldwide do not have mental health legislation and half of those that do enacted their laws over 15 years ago. Generally, lower income countries are more likely to have older legislation [ 67 ].

In the European Union, for example, anti discrimination laws are now mandatory under the Article 13 Directive [ 68 ]. Such laws must make illegal all discrimination in the workplace on grounds that include disability, and also set up institutions to enforce these laws. The time is therefore right is share experiences between different countries on how successful such laws have been to reduce discrimination against people with mental illness and to understand more clearly what is required both for new legislation elsewhere and for amendments to existing laws that fall short of their original intentions.

International organisations such as the WHO can also contribute towards better care and less discrimination by indicating the need for national mental health policies and by giving guidance on their content. In 2005, for example, only 62% of countries in the world had a mental health policy [ 67 ]. In Europe, health ministers have signed a Mental Health Declaration and Action Plan which sets the following priorities:

foster awareness of mental illness

tackle stigma, discrimination and inequality

provide comprehensive, integrated care systems

support a competent, effective workforce

recognise the experience and knowledge of services users and carers [ 65 , 69 , 70 ].

The strongest evidence at present for active ingredients to reduce stigma pertains to direct social contact with people with mental illness, which has been shown to be effective in relation to police officers, school students, journalists and the clergy [ 33 , 71 – 73 ]. At the national level, there is emerging evidence that a carefully co-ordinated approach based on using social marketing techniques, namely advertising and promotional methods designed to achieve a social good rather than sales of a commodity, have produced benefits in Australia, New Zealand and Scotland [ 16 , 17 , 74 ]. The challenge in the coming years will be to identify which interventions (whether directed towards knowledge, attitudes or behaviour) are most cost-effective in reducing the social exclusion of people with mental illness.

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Acknowledgements

This study was funded in relation to an National Institute for Health Research (NIHR) Applied Programme grant awarded to the South London and Maudsley NHS Foundation Trust (AK and EB), and in relation to the NIHR Specialist Mental Health Biomedical Research Centre at the Institute of Psychiatry, King's College London and the South London and Maudsley NHS Foundation Trust (GT).

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Thornicroft, G., Brohan, E., Kassam, A. et al. Reducing stigma and discrimination: Candidate interventions. Int J Ment Health Syst 2 , 3 (2008). https://doi.org/10.1186/1752-4458-2-3

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MINI REVIEW article

Stigma and discrimination during covid-19 pandemic.

• 1 Department of Applied Psychology, Ramanujan College, University of Delhi, New Delhi, India
• 2 Department of Psychology, Banaras Hindu University, Varanasi, India
• 3 Department of Applied Psychology, Vivekananda College, University of Delhi, New Delhi, India

The COVID-19 pandemic has been instrumental in creating a dramatic shift from people's need to live in mutual association toward a desire to stigmatize distinctive others. Pandemic seems to be causing othering. Stated simply, stigmatization is a social process set to exclude those who are perceived to be a potential source of disease and may pose threat to the effective social living in the society. Based on the secondary evidence collected from news published online or in print, the present article delves into stigma associated with the COVID-19 pandemic among different social groups in the Indian society and the mounting cases of prejudice based on race, class, and religion. It also presents insights into the varied manifestations, and the deleterious consequences of COVID-19 inspired othering brought to its potential targets in India.

Introduction

Humanity today is facing one of the biggest challenges of the century. The novel coronavirus is spreading rapidly to the extent of being declared as a pandemic across the world. The spread of the COVID-19 pandemic has raised concerns of everyone across the globe. People are in dismay for what is happening with them and at the same time are disturbed to see the conditions of others, particularly the marginalized. There is a sudden shift in people's daily routines. Apart from the fears, anxiety, and sadness, people's sense of irritability has started piling up. Amid such a deranged spread of COVID-19, one of the important concerns that is even more deleterious than all the above highlighted negative impacts and needs to be urgently attended to is stigmatization associated with the pandemic.

People have been witnessed to undergo a dramatic shift from their willingness to live in mutual association to an urge to practice stigmatization ( 1 ) of individuals, groups, and nations who are comprehended as potential sources of virus contagion to others. In other words, the pandemic seems to be causing othering ( 2 ), manifesting at the global as well as at the local context leading to a tremendous loss of social capital. The stigmatizing behaviors in the present context are being guided by the famous adage “better safe than sorry” ( 3 ) that explain that how the fear of something unknown and uncertain ( 4 ) accounts for the negative attitudinal reactions directed toward the people who are infected or are suspected and the ones considered responsible for the spread of the virus.

The present article takes a look at the increasing cases of “othering” that are characterizing the societal response at large. The focus will be on different social groups that are the targets of prejudice and discrimination so rampant during the COVID-19 crisis in India. It includes prejudice based on religion, occupation, race, and economic class.

The Psychology of Stigma

The term stigma was first introduced by Goffman ( 5 ) to refer to visible characteristic features (such as cut of burnt) of the individuals that make the society devalue and consider them unfit for their inclusion in the mainstream society. Subsequent scholars have attempted to define the term from their unique perspectives ( 6 ) explaining the term with respect to relationship between mark and discrediting dispositions ( 7 ), a sociocultural-driven phenomenon ( 8 ), interwined in the nexus of power dynamics ( 9 ), which function to reinforce the preexisting power differentials ( 10 – 12 ).

The stigmatization phenomenon has been the intriguing areas of exploration pertaining to the specific context in which it unfolds. The evolutionary approach to stigmatization provides a convincing answer to the origin of stigmatization ( 8 ). Stigmatization is practiced as an adaptation ( 13 ) following a principle of discriminate sociality ( 14 – 16 ) in the perception of danger, threat, or challenges to one's social living, and attempts are made henceforth to safeguard oneself from various such foreseen or unforeseen impediments such as getting prone to infectious diseases, being advocated to the values contrary to their own, and having an intimidating out-group, etc. ( 8 , 17 , 18 ). The stigma of COVID-19, in the present context, could be comprehended as a social process that sets to exclude those who are perceived to be a potential source of disease and may pose threat to the effective social living in the society ( 13 , 19 ).

Several theoretical approaches provide explanations to the phenomenon of stigmatization and the way it folds. In the following sections, we will try to explain the origin of stigmatization, theoretical approaches, highlighting the unfolding of the phenomenon, the purpose it serves for the stigmatized, and the effects the stigmatized reap out of their experiences of negative attitudinal reactions of the society toward them.

One of the earliest theories, the social interactionist theory of stigma ( 5 ), talks about the negative self-conceptualizations held by the stigmatized when they comprehend a discrepancy, during social interactions, between what the society expects them to be and what they truly are. As a result, the stigmatized experience shame for not being able to meet the expectations of the society and experience anxiety and fear of being rejected by the society.

The labeling theory by Becker ( 20 ) explains that people attach labels to others in order to ease their understanding of their social world around. The theory explains stigmatization as a phenomenon unfolding against those who are labeled as deviant based on their specific attributes or behaviors perceived as contrary to the acceptable standards in the particular sociocultural framework. As a result, stereotypes are attached to the deviant labels ( 5 , 9 , 21 ), and the targets become the recipients of negative psychosocial and emotional reactions of the society, hence stigmatized ( 22 ). The chances of stigmatization are direct functions of power and resources of the targets, level of tolerance for the deviance by the society, social distance between the two, and visibility of the deviance ( 23 ).

Another explanation for stigmatization comes from social identity theory ( 24 , 25 ), which draws it from the self-categorization theory (Turner, 1979). According to this theory, self-concept of individuals draws heavily from their belongingness to social groups ( 25 ), which gives rise to intergroup comparison ( 26 ). Emphasizing upon the superiority of one's own group, a phenomenon called ethnocentrism ( 27 ), people set to positively evaluate and favor the members of their own group (in-group) and engage in derogatory attitudinal reactions (stigmatization) against the out-group for it reaps them benefits of elated sense of self-esteem.

As against the previous theories that talk about the explanations for the unfolding of stigmatization in a particular sociocultural context, the model of stigma-induced identity threat ( 28 ) highlights the reactions of the stigmatized on being exposed to the derogatory treatments of the society. In addition to experiencing stress, the reactions of the stigmatized are influenced by the way they appraise or evaluate the stigmatizing situations based on their collective representations (awareness about one's stigmatized status in the society, the dominant stereotypes associated, and the recognition of being discriminated against) ( 29 ), immediate situational cues (the characteristics of the presenting situation that could be perceived in terms of the amount of threat it brings to the social identity of the stigmatized) ( 30 ), and individual characteristics (the personal characteristics of the stigmatized that catalyze the influence of the stressful situations on the stigmatized, like the extent to which they identify themselves with their stigmatized group–( 31 )). Identity threat results when the situation is appraised by the stigmatized as harmful and exceeds the coping resources available with them to overcome it, resulting in several voluntary and involuntary reactions.

The process of stigmatization has several benefits for the stigmatizers ( 32 ) that serve to explain why people stigmatize others. Stigmatization not only helps perceivers to form a holistic and a simplified understanding of the targets ( 33 – 36 ), but also allows them to go beyond the available information about the targets and make judgments about their personality and behaviors ( 37 ). Stigmatizers strive to cultivate their biological and reproductive fitness through stigmatizing the diseased ( 19 ), dominating and exploiting others ( 11 , 12 ), for example, which aids a successful transfer of genes to the offspring ( 38 , 39 ).

Stigmatization also helps stigmatizers in maintaining inequality through power differentials ( 19 ), preserving important resources for themselves ( 8 , 40 , 41 ), such as wealth, power, and a reputed status ( 19 ), exploiting the stigmatized to serve their purpose ( 19 , 42 , 43 ) and emphasizing control over them by practicing derogatory behaviors against them ( 44 ). These practices serve to boost the self-esteem and well-being of the stigmatizers, as well as serve to reduce their existential anxiety [Terror management theory by ( 45 )].

Several studies in the past have studied the negative attitudinal reactions of the society against the stigmatized in relation to a number of physical and psychological health problems, such as AIDS ( 46 ), mental illnesses ( 16 , 47 , 48 ), facial disfigurement ( 49 ), cancer, leprosy, and physical disfigurement ( 50 ), and in relation to various sociological factors, such as homelessness ( 51 ), sexual orientation ( 52 ), social class ( 53 ), caste ( 54 ), etc., where the stigmatized become the passive recipients of negative emotional reactions from the powerful others ( 55 ).

Prejudices and discriminatory reactions against the stigmatized have also been the area of concern in the context of epidemics such as severe acute respiratory syndrome (SARS) ( 56 ) and H5N1 ( 57 ). Fear of contracting has been understood as one of the major precursors for the people to indulge in stigmatizing the infected ( 58 ) and the suspected because of their close-knit association with the spread of the disease [( 56 ), p. 359]. Hatred is witnessed to be a common reaction of the society against the stigmatized during epidemics, particularly during modern times ( 59 ).

Although the stigma associated with pandemic has been a well-established phenomenon [( 56 ), p. 359], due to its contextual nature ( 8 , 13 , 29 , 60 ), the way it unfolds might vary depending on the context it finds its existence in.

The present ongoing situation of COVID-19 pandemic and its impact not only on the physical and psychological health but also on the way people are interacting with others are compelling enough to initiate analytical examination of stigma and discrimination related with COVID-19. This seems essential for the effective control of the disease, and the negative consequences of stigma aligned with being infected with coronavirus are extremely pernicious, the same way those were evident during SARS [( 61 ), p. 729] and H5N1 outbreak ( 57 ). The psychological burden of such treatments strongly influences people's willingness to seek treatment or even let others know about ( 62 ). This not only impedes the process of effective management and minimization of the spread of the disease but also brings debilitating consequences for the overall well-being of the survivors and their relatives [( 63 ), p. 108].

At this backdrop, using an analytical perspective, the present article delves into examining the way COVID-19–related stigmatization has unfolded itself against the specific sections of the Indian society and to gain a holistic understanding of the experiences of stigmatization as experienced by the people after the outbreak COVID-19 pandemic. An understanding of these would help us understand the way in which a crisis situation may lead to the segmented organization of the society in terms of strengthening of already existing categorizations, as well as emergence of new categorization. In addition, such an understanding is expected to supplement the government about the potential impediments that stigma is assumed to be creating in withholding the people's tendency of cause a delay in getting themselves tested or share their medical condition of being infected with coronavirus because of the fear of being stigmatized.

Methods and Procedure

The present review is based on a careful review of literature on stigma during a pandemic and/or medical emergency and on the thematic analysis of news reports published online and/or in print editions since the outbreak of this pandemic in India. While the literature served as a vantage point to evaluate the social reactions of the current pandemic, the newspaper reports were treated as the sources of data related to the experience of stigma during COVID-19 pandemic. The news reports presenting negative reactions and/or experiences and the stigmatized treatments directed against people during the COVID-19 pandemic were thematically analyzed, and anecdotes were extracted to describe the stigma related to the dejection, derogation, devaluation, exclusion, discrimination, etc., associated with COVID-19.

Stigma and Discrimination in India: Emerged Themes

From the careful analysis of the content extracted through the newspaper reports, several themes emerged indicating the stigmatic expressions and behaviors during the pandemic. The following section discusses these emergent themes in the light of the available literature explaining stigmatization.

Stigmatization of the Suspected and Actually Infected Individuals

Since the outbreak of the pandemic in India, there existed a negative perception toward those infected with the disease. The COVID-19 patients are accused of being ignorant and negligent, thereby being held responsible for having contracted the virus ( 64 ). The COVID-19 patients were being stereotyped as the active spreaders of coronavirus and were being treated as the passive acquirers of the disease. Such a stereotype led the society to adopt several negative treatments (ranging from social media posts against them, stopping their entry into the residential areas, and spreading rumors against them on the basis of their religion, class, and caste) directed against them. Being an atypical condition, the devaluation associated with the mark of COVID-19 is indelible ( 19 ). Probably, that is why the consequences attached to its stigmatization are so devastating that even the formerly diagnosed continue to be stigmatized ( 65 – 67 ), and even after defeating the virus, they have not been able to free themselves from being shunned by society. They are reported being treated as untouchables, receiving the humiliating taunts, and fingers pointed against them and their family; their lane of residence has been named as “corona wali gali” (corona street), and the associated burden is strong enough that it has even compelled them to sell their own house ( 68 ). The fear among the people is so intense that it has led them to blame the scapegoats—especially the poor, laborers, daily wagers, and the migrants ( 69 ). Reports indicate that the people working in Delhi (India) and residing in Haryana (India) were negatively labeled as “corona carriers” by the Home Minister of Haryana, devaluing the former for the possible spread of the contagion ( 70 ). Even the doctors were not spared from being titled as the “carriers” of coronavirus ( 71 ). Therefore, not only the infected but even the suspected (due to the high risk of being infected) become the potential recipients of stigmatization ( 72 ).

There exists sufficient literature that highlights stigmatizing reactions of society against the infected during pandemics such as SARS outbreak [( 56 ), p. 359] and shows that communicable negative health conditions bear stigma ( 73 ). The stigma toward the infected or feared to be infected with COVID-19 could be explained by the terror management theory ( 45 ). Because of the lack of any medication or vaccine available for COVID-19 ( 74 ), a lot of terror has been evident among the people at large ( 75 ). This heightened existential anxiety among the people acknowledging the possibilities of their mortality due to contagion with coronavirus ( 76 ) seems instrumental in triggering set of defenses in the form of negative attitudinal reactions against those who threaten people's belief in their immortality ( 77 , 78 ) i.e., the COVID-19 infected, their associates, and the suspects of it.

The evolutionary perspective ( 8 ) of stigmatization also sets to explain such negative treatments against the COVID-19 infected. According to this perspective, the stigma serves as the means to avoid and make distance from the coronavirus contagious individuals or groups ( 1 ) to safeguard themselves from catching the infection (6, p. 58). Such attitudinal reactions could also be understood in the light of labeling theory ( 20 ). Because the infected are labeled as different based on their unacceptable medical condition, they reap stigmatization from the society.

The notion of double stigmatization was also seen in some cases. A deaf-mute, for example, was deserted by his own family after they suspected him to be coronavirus positive that was later confirmed as not bearing the virus ( 79 ). Similarly, a coronavirus-negative deceased elderly was abandoned by the family suspecting the former as highly vulnerable to catch the virus ( 80 ).

The Stigma Based On Race: The Case of Northeast Indians

The easternmost part of India, comprising eight states—Assam, Sikkim, Arunachal Pradesh, Manipur, Nagaland, Meghalaya, Mizoram, and Tripura—is known as Northeast India. The residents from the Northeast India have been the targets of racism from the mainlanders in India for a long time as they have typical mongoloid features, which are similar to the features of Chinese individuals ( 81 ). The people of Northeast India have mostly borne the brunt of racism and discrimination and have been often regarded as foreigners in their own country. The racism toward Northeast Indians have heightened during the COVID-19 pandemic, and many cases were reported ( 81 ) where Northeasterners were called “corona” spat at, socially avoided, asked to vacate their houses by their landlords, beaten, suspended from employment, or had difficulty in accessing health care ( 82 , 83 ). These racial attacks and discrimination have also been evident in the prestigious educational institutions of the nation including Kirorimal College, affiliated to University of Delhi, Tata Institute of Social Sciences, Mumbai, as well as National Council for Educational Research and Training, Delhi ( 84 ).

Literature reports racism to be an important factor leading to an undue spread of disease in the minority community ( 85 ) even leading to their deaths ( 86 ). However, the experience of stigma by Northeastern individuals in India has mostly been due to their association and facial similarities with Chinese individuals who are also stigmatized by many to be the reason for the origin of this pandemic.

The Stigma Based on Profession: State of Health Care Professionals and Police Personnel

During this COVID-19 crisis worldwide, every country is trying to the best of its abilities and resources, to curb the spread of the pandemic. Individuals, groups, and communities are coming together and are presenting ultimate examples of prosocial behavior by helping those in need. Among them, there are doctors, nurses, other health care workers, police officers, and municipal workers who are risking their lives to serve their nation. India is no exception to this.

However, the doctors who are making arduous efforts to save the lives of the patients ( 87 , 88 ) and the police officials who are working day and night, away from their families [( 89 – 91 )], are being ill-treated by the society ( 92 , 93 ). They are fearful and are experiencing frustration arising out of their hard struggle and above all are facing social stigma ( 87 , 94 , 95 ) that does not even end with their death ( 96 ).

People at the forefront of the war against the pandemic (also called as coronavirus warriors) are becoming ostracized by their neighbors, landlords, taxi drivers, and even their own family members. Having left with no other option, doctors and nurses have had to sleep in the staff rooms and even in the washrooms of hospitals. Taxi drivers have also refused to serve them ( 97 ). The nurses have become homeless because of being shunned, attacked, and accused by their fearful landlords ( 87 , 97 ) and have faced abusive and vulgar comments ( 98 ). Several cases of harassment ( 80 ), assaults, and false accusations of spreading the virus ( 99 ) have also surfaced against them. This has left them experiencing dismay ( 100 ), humiliation, and hurt, causing them to leave their homes ( 71 ).

Such ongoing stigmatized treatments directed against doctors, other health care workers, police officers, and municipal workers present classic representation of stigma by association ( 5 , 101 ). Social stigma in this context becomes a function of disadvantageous alliances wherein even people who were not initially a part of the stigmatized group (doctors, nurses, and police) become the targets of stigma [because they are exposed the maximum to COVID infected patients; ( 102 )].

The Stigma Over the Death

The social stigma of COVID-19 has not even shown mercy to the dead bodies of the patients. There have been violent disruptions or prohibitions of funeral ceremonies ( 80 ) and burials ( 103 , 104 ) of COVID-related deaths. Fearful officials of Nigambodh Crematorium in Delhi refused to perform the last rites of the infected dead bodies because of the sheer lack of knowledge about how the virus spreads ( 105 ). People in Chennai opposed the cremation of a doctor and assaulted the medical staff on duty ( 96 , 106 , 107 ) for the same reason. Residents of village Verka, Amritsar, had denied the cremation of Padam Shri Awardee and Hazoori Ragi, Mr. Nirmal Singh ( 108 ). Similarly, people in West Bengal protested against and condemned cremations of COVID-19 deaths at regular cremation places ( 109 ).

People's stigmatizing reactions for the dead family member indicate the strong and deep-seated embeddedness of irrational fear and threat that the virus has brought with itself. Several families in India denied claiming the dead body of their own kin members ( 110 ). Some have refused to do their last rites ( 111 ). Not even the ashes were collected by them, fearing the contagion; families forget about having their last glimpse before cremation ( 112 ).

Under such disturbing circumstances, many non-governmental organizations have taken the initiative of performing the last rites of the abandoned deceased. Abdul Bhai's Ekta Trust, for example, was accorded with the responsibility by the Surat Municipal Corporation, for the cremation and burial of COVID-19–infected bodies as per their respective religion ( 113 ).

The Stigma Based On Religious Identity: MARKAZ Congregation

During March 13–15, 2020 a religious meeting (congregation) was held constituting of members of Tablighi Jamaat, an Islamic missionary and reformist organization (majorly of Sunnis- an Islamic subgroup), from all over the world at the Nizamuddin Markaz (Center) in Delhi. Later it was found that majority of these members were coronavirus-positive, and before they could be tested and contained, they returned back to their respective places all over India. The fear of the spread of the virus among general public was at the peak during that time, and the entire Muslim community at that time was stigmatized as the spreaders of the virus. The stigmatization of the whole Muslim community has been at the forefront of Indian public's reaction to COVID-19. Some political leaders were witnessed calling the Jamaat event as “corona terrorism” ( 114 ), and the congregation attendees as the “enemies of humanity” ( 115 ). Such reactions fueled the feelings of hatred and misplaced undue blame for the spread of the virus to this community.

In accordance with the dual model of impression formation ( 116 ) and the suppression justification model ( 117 ), holding a handful of Muslim Jamaatis' responsible for the spread of COVID-19 infections at augmented levels among the Indians could be contemplated as sufficient condition for cultivating the feeling of hatred and disgust for the whole Mohammedan community ( 114 ).

In accordance with the Social Identity theory ( 25 ), and Sumner's ( 27 ) conceptualization of ethnocentrism, the strong prejudices ( 118 ) exhibited against the social identity ( 119 ) of the Muslim community could be understood as a motivational act ( 120 ). Scheff ( 23 ) explains the level of tolerance for the target as a determining factor of the strength of the stigmatizing reactions directed against them. There has been a long history of Hindu-Muslim religious prejudice and discrimination reflecting less intergroup tolerance. The exaggerated negative reactions of society against the Muslim community could also be attributed to the role of media ( 121 , 122 ). Sensationalized and inaccurate reporting, like showing doctored videos of Jamaat members spitting on others ( 114 ), has contributed to public hysteria and widespread negative perception of the Muslim community. The consequence was the surge in hostility, segregation, and violence projected toward the whole Muslim community ( 123 ) and twitter hashtags saying “corona jihad” ( 114 ).

These acts have functioned to validate that Muslims' subvert position is well-deserved ( 54 , 101 ) and have contributed to the entrenchment of the already existing gaps that exist between the religious groups in the society ( 10 , 101 , 124 , 125 ).

Stigma Against the Migrant Workers

A significant chunk of the Indian population migrates from their villages to different states and cities in search of employment and work largely in the unorganized/informal sector. When the nationwide lockdown was suddenly announced as a quick response measure to curb the pandemic, the country was neither prepared nor had foreseen the consequences the lockdown would have for the migrant workers, daily wagers, laborers, house helps, street vendors, barbers, plumbers, mechanics, and many more. The lockdown was perhaps the first step toward othering. It had an inbuilt bias toward the privileged when it was presumed that people could stay locked up in their homes and survive, without considering the fact that how would migrant workers and daily wagers survive even for a day without work with their hand-to-mouth existence. And within a week of lockdown, India witnessed and continued to witness over months one of the biggest humanitarian crises—the mass migration of millions of workers propelled by their socioeconomic hardships. The poor migrant workers were left with no choice, but to leave for their hometowns. The central and state governments had not envisioned this mass exodus. However, with the public transport system being shut, they were compelled to use other modes such as bicycle and even foot, for covering distances of over thousands of miles. There were many videos and photographs circulating on news media, highlighting the suffering of the poor—exhausted men, women, and children, walking empty stomach, carrying their belongings, with the sun glaringly over their heads ( 126 , 127 ). It is humiliating to become a kind of refugee in one's own country and have negligible social security. As pointed out by Gupta ( 128 ), white-collar workers and students who returned home after lockdown from overseas as well as other Indian states were not labeled as “migrants”; the label was reserved to refer to people belonging to the lower socioeconomic strata whom Gupta ( 128 ) calls “collarless workers.” The term “migrant” strategically paints a dehumanizing picture of these workers in mass media. Scheff ( 23 ) asserts that the chances of labeling specific kinds of people as deviant more than the others are the function of social distance between them and the society. This aptly explains the differential treatment poor received as compared to the white collar dominant others.

The stigma of being poor was highlighted when the government made arrangements for bringing back Indian students, tourists, and others who were stranded in foreign countries, but paid little attention to the plight of these workers. Other incidents were when the migrant workers were sprayed down with disinfectant by health/civic departments on two occasions ( 129 , 130 ). The act was not only unreasonable but also highly undignified, highlighting stigmatization to be the function of the social status of the people ( 131 ). It objectified the poor workers as contaminated with the virus. It also mirrored the racist treatment received by Latinos on the American border, who too were dehumanized in the exact same way a few decades earlier. The predicament of the migrant workers strongly suggests how fear-ridden powerful systems victimize and blame the helpless marginalized groups.

The Consequence of Stigma Due to COVID-19

The model of stigma-induced identity threat talks about the negative consequences stigmatization brings for the overall well-being of the people when they appraise the stigmatizing situations and identity threatening ( 28 ). The patients of COVID-19 are stigmatized and hence are bearing the consequences that are far more pernicious than the condition in its own self ( 1 , 132 ). Social rejection has created a barricade between them and society ( 122 ) with repercussions for their physical, psychological health, and well-being ( 64 ). The patients are fearful of being shamed and stigmatized by society, extreme enough to exhibit the symptoms of hysteria ( 64 ). Some have also equated their distress to posttraumatic stress disorder ( 133 ).

The director of All India Institute of Medical Sciences, Delhi, warned about the perceived dread of being stigmatized among the people leading them to refrain from getting tested ( 134 , 135 ). The social ostracism is responsible for people not seeking treatment or reporting symptoms and thus impeding an early detection of the virus and its effective control ( 62 , 102 , 122 ). The conditions are not even favorable for those who have tested negative for coronavirus. An individual in Madurai ( 136 ) and another one in Himachal Pradesh ( ? ) committed suicide on facing social boycott even after being tested negative for coronavirus.

A recent survey ( 137 ) revealed that 61% of people in India are suffering from mental health concerns, with the percentage of women outweighing that of men. The deteriorated psychological health was mainly attributed to the lockdown and the associated difficulties ( 137 ). Among others, one of the significant concerns raised by the National Commission for Women is the rising quantum of domestic violence cases in India amid lockdown ( 71 , 138 ). While lockdown and social distancing enforced by the government in the prevailing pandemic have contributed to an extent in curbing the spread of the virus, it has also contributed in the people experiencing depression ( 139 , 140 ), anxiety, terror, panic, heart disease arising out of loneliness ( 140 ), and committing suicides ( 141 ). People are apprehensive about the possibilities of unknowingly carrying the coronavirus ( 142 – 144 ). All these ill effects of the pandemic when associated with the rising stigmatization and discrimination are expected to have far-reaching consequences for the Indian society.

Other stressful concerns of people include witnessing the difficulties of the underprivileged and facing the economic crisis, increased frustration with other people, disordered regime, unpredictable future and the virus itself ( 145 ), maintaining physical distance, curtailed travel, and lack of or incorrect information ( 146 ).

India's Reactions and Measures to Reduce Stigma

Taking serious consideration of the entrenched stigma associated with the disease in Indian society, the Government of India has been taking active and cognizant measures to curb it. Particularly important is the launch of a caller tune, a public health communication strategy, and appealing to the general public to fight the coronavirus disease, not the diseased. The government has also tried to boost the self-esteem of the doctors, health care professionals, police, and hygiene staff by calling them “corona warriors” and encouraging the general public to pay tribute to the health care professionals. The entire country got together in clapping for the coronavirus warriors from their houses' balconies, they lit up candles outside their houses, and Indian fighter jets showered flowers on the hospitals housing COVID-19 patients. These measures played an important role in reducing stigma and fostering togetherness.

By the end of March, within 15 days of announcing the nationwide lockdown, the Indian Finance Minister, N. Sitharaman, announced INR 1.7 trillion relief package labeled the Pradhan Mantri Garib Kalyan Yojana. It was projected that under the scheme, 800 million Indians would receive 5 kg of wheat and rice for 3 months (in addition to the 5 kg they were already receiving). One kilogram of the preferred pulse was added to this distribution. Furthermore, 60 million farmers registered under the PM-KISAN scheme (who received INR 6,000 per year in three equal installments) were given the first installment upfront for the fiscal year starting April 2020. MNREGA workers' wages were increased from INR 182/— to INR 202/—. The government also provided relief for other marginalized groups, allocating INR 1,000 each for 30 million senior citizens, widows, and disabled Indians and INR 500 per month for 3 months to the 200 million women who were Jan Dhan account holders. Furthermore, women covered under the Ujwala scheme (83 million families) were allocated free LPG cylinders for 3 months. Over 2 crore construction workers received financial support totaling Rs 3,066 crore under the Building and Construction Workers' Fund.

All these actions were aimed at retroactively easing the crisis that was hurled at the Indian working class. At the fore of promising proactive measures to protect these workers is the effort spearheaded by the UP government. They have set up a Migration Commission for the employment of laborers in the state to ensure their social–legal–monetary rights. Any effort toward rehiring workers post lockdown would now require states to seek UP government's permission and follow protective procedures that the commission would outline.

Apart from schemes aimed at helping the working class, the government also delayed the tax filing deadline under “Vivaad Se Vishwas Scheme” from March 31 to June 30, 2020, and expedited the income-tax refunds process, to release all refunds up to INR 0.5 million.

Summary and Conclusion

The above exposition clearly establishes the deep fissures that underlie the collective, which manifest in times of crises, such as a pandemic. It is rightly said that epidemics reveal who and what is genuinely valued in a society. The power hierarchies come to the fore. This article highlighted stigma associated with being an infected patient, or a close contact of someone infected, along with belonging to a particular race, religion, and social class. It is important to note that stigma reduces health-, help-, and treatment-seeking behavior and needs to be mitigated, apart from the focus on COVID-19 treatment and prevention. Global Health communication plays an important role in the construction of diseases, their social perception, and resulting psychological issues. Thus, all relevant stakeholders, including the government, media and local administrative bodies, as well as hospitals, ought to mitigate stigma through a multipronged approach. Logie and Turan ( 146 ) suggest that balancing measures of containment and prevention of the pandemic such as physical distancing and travel restrictions, with appropriate information/public health messages and involvement of communities adversely affected by the pandemic (such as females, LGBTQI, marginalized races, poor), can help reduce the stigma.

Nature has made us all equal. It is us who create divisions in society for our own benefit. Stigmatization serves this purpose. But what it also does is create boundaries at the interpersonal, intergroup, and international levels that are often impossible to undo. There are those who actually commit crimes, and there are also several others who only reap the consequences of being associated with the negative, whether it be in terms of the nature of their work, shared social identity—family, religion—or as simple as being a scapegoat to the injustices that projected their way by the society. What is important to learn from all this is that it reflects a sheer loss of human ability to distinguish between the bad and good and the basic human essence of being kind and helpful toward others. And if this would continue, it is not going to serve any fruitful purpose in the long run for we all are humans first, and the association that we share with our family, religion, profession, socioeconomic status, and many more comes later.

Author Contributions

DB, TS, SV, and SS conceptualized and collected materials. DB prepared the initial draft. TS and SV reviewed and improved the draft. SS made final revisions. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: COVID 19, stigma, stigmatization, discriminatory behaviors, victimization, social identity

Citation: Bhanot D, Singh T, Verma SK and Sharad S (2021) Stigma and Discrimination During COVID-19 Pandemic. Front. Public Health 8:577018. doi: 10.3389/fpubh.2020.577018

Received: 28 June 2020; Accepted: 04 November 2020; Published: 12 January 2021.

Reviewed by:

Copyright © 2021 Bhanot, Singh, Verma and Sharad. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Tushar Singh, tusharsinghalld@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Reducing stigma and discrimination associated with COVID-19: early stage pandemic rapid review and practical recommendations

Affiliations.

• 1 Health Service and Population Research Department, Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychology, Psychiatry & Neuroscience, King's College London, London, UK.
• 2 WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation; Department of Neuroscience, Biomedicine and Movement Sciences; Section of Psychiatry, University of Verona, Verona, Italy.
• 3 NLR International, Amsterdam, Netherlands.
• 4 CBM Global, and Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
• 5 Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
• 6 KNCV Tuberculosis Foundation, The Hague, Netherlands.
• 7 Global Mental Health Peer Network, Johannesburg, Gauteng, South Africa.
• PMID: 33504412
• PMCID: PMC7884669
• DOI: 10.1017/S2045796021000056

Aims: To develop recommendations for strategies and interventions to reduce stigma and discrimination related to coronavirus disease 2019 (COVID-19), through reviewing and synthesising evidence in relation to COVID-19 and other disease outbreaks and infectious/stigmatised conditions from systematic reviews and primary studies and recommendations from additional materials.

Methods: Rapid review, drawing on the World Health Organization's (WHO) methodology for developing interim guidelines during health emergencies. PubMed/MEDLINE, PsycINFO, Cochrane Central and Campbell Collaboration searched up to mid-April 2020. Searches were supplemented by reference-searching and expert recommendations. Searches were designed to identify: (1) systematic reviews (<10 years), or (2) primary intervention studies (no date limit) reporting evidence on anti-stigma interventions (in relation to COVID-19 or other infectious/stigmatised conditions) or (3) additional relevant materials. Data were extracted on population, intervention, outcome and results. These data were compiled into evidence summary tables and narrative overviews. Recommendations on strategies for COVID-19 stigma-reduction were developed using the WHO 'Evidence to Decision' framework approach. The review protocol was registered with PROSPERO (registration ID: CRD42020177677).

Results: The searches identified a total of 4150 potentially relevant records, from which 12 systematic reviews and 29 additional articles were included. Overarching considerations and specific recommendations focus on: (1) language/words used in relation to COVID-19 and affected people; (2) media/journalistic practices; (3) public health interventions; (4) targeted public health interventions for key groups and (5) involving communities and key stakeholders.

Conclusions: These recommendations represent the first consolidated evidence-based guidance on stigma and discrimination reduction in relation to COVID-19. Mitigating the impact of stigma is critical in reducing distress and negative experiences, and strengthening communities' resolve to work together during exceptional circumstances. Ultimately, reducing stigma helps addressing structural inequalities that drive marginalisation and exacerbate both health risks and the impact of stigma. Administrations and decision makers are urged to consider integrating these recommendations into the ongoing COVID-19 response.

Keywords: Coronavirus; emergency response; health inequalities; public health.

Publication types

• COVID-19 / psychology*
• Discrimination, Psychological*
• Disease Outbreaks
• Public Health
• Social Discrimination*
• Social Stigma*

Grants and funding

• 001/WHO_/World Health Organization/International
• MR/R023697/1/MRC_/Medical Research Council/United Kingdom
• MR/S001255/1/MRC_/Medical Research Council/United Kingdom

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Open Access

Peer-reviewed

Research Article

Strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings: A mixed-methods systematic review

Roles Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Gender and Women’s Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia

Roles Formal analysis, Investigation, Methodology, Writing – review & editing

Affiliation Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America

Affiliations Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia, Nossal Institute, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia

Affiliation Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States of America

Affiliations Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America

Roles Data curation, Writing – review & editing

Affiliation Brownless Biomedical Library, University of Melbourne, Melbourne, Victoria, Australia

Roles Conceptualization, Funding acquisition, Writing – review & editing

Affiliation Department of Sexual and Reproductive Health and Research, including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Writing – original draft, Writing – review & editing

• Meghan A. Bohren, 
• Martha Vazquez Corona, 
• Osamuedeme J. Odiase, 
• Alyce N. Wilson, 
• May Sudhinaraset, 
• Nadia Diamond-Smith, 
• Jim Berryman, 
• Özge Tunçalp, 
• Patience A. Afulani

• Published: June 15, 2022
• https://doi.org/10.1371/journal.pgph.0000582
• Peer Review
• Reader Comments

Stigma and discrimination are fundamental causes of health inequities, and reflect privilege, power, and disadvantage within society. Experiences and impacts of stigma and discrimination are well-documented, but a critical gap remains on effective strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We aimed to address this gap by conducting a mixed-methods systematic review and narrative synthesis to describe strategy types and characteristics, assess effectiveness, and synthesize key stakeholder experiences. We searched MEDLINE, CINAHL, Global Health, and grey literature. We included quantitative and qualitative studies evaluating strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We used an implementation-focused narrative synthesis approach, with four steps: 1) preliminary descriptive synthesis, 2) exploration of relationships between and across studies, 3) thematic analysis of qualitative evidence, and 4) model creation to map strategy aims and outcomes. Of 8,262 articles screened, we included 12 articles from 10 studies. Nine articles contributed quantitative data, and all measured health worker-reported outcomes, typically about awareness of stigma or if they acted in a stigmatizing way. Six articles contributed qualitative data, five were health worker perspectives post-implementation and showed favorable experiences of strategies and beliefs that strategies encouraged introspection and cultural humility. We mapped studies to levels where stigma can exist and be confronted and identified critical differences between levels of stigma strategies aimed to intervene on and evaluation approaches used. Important foundational work has described stigma and discrimination in sexual and reproductive healthcare settings, but limited interventional work has been conducted. Healthcare and policy interventions aiming to improve equity should consider intervening on and measuring stigma and discrimination-related outcomes. Efforts to address mistreatment will not be effective when stigma and discrimination persist. Our analysis and recommendations can inform future intervention design and implementation research to promote respectful, person-centered care for all.

Citation: Bohren MA, Vazquez Corona M, Odiase OJ, Wilson AN, Sudhinaraset M, Diamond-Smith N, et al. (2022) Strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings: A mixed-methods systematic review. PLOS Glob Public Health 2(6): e0000582. https://doi.org/10.1371/journal.pgph.0000582

Editor: Marie A. Brault, The University of Texas Health Science Center at Houston School of Public Health - San Antonio Campus, UNITED STATES

Received: July 19, 2021; Accepted: May 13, 2022; Published: June 15, 2022

Copyright: © 2022 Bohren et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data available within the article or its supplementary materials.

Funding: This research was made possible by the support of the American People through the United States Agency for International Development (USAID) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO. (MAB, PA). MAB’s time is supported by an Australian Research Council Discovery Early Career Researcher Award (DE200100264) and a Dame Kate Campbell Fellowship. PA’s time is partially supported by a Eunice Kennedy Shriver National Institute of Child Health & Human Development Career development award (R00HD093798). AW’s time is supported by a National Health & Medical Research Council Postgraduate Scholarship (APP1151585). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Sexual and reproductive health and rights (SRHR) are essential to achieve equitable and sustainable development [ 1 ]; however, persistent inequities remain related to unintended pregnancy, pregnancy and childbirth complications, unsafe abortion, infertility, sexually transmitted infections (STIs), reproductive cancers, and gender-based violence. SRHR are integral components of health, social, and economic development [ 1 ], but remain out of reach for many people globally. Political ideologies, social and cultural expectations around gender equality, reproductive choices, and sexuality continue to threaten SRHR [ 1 ]. The 2030 Sustainable Development Agenda highlights two targets specific to achieving universal access to sexual and reproductive health, health-care services and reproductive rights (targets 3.7 and 5.6) [ 2 ]. While this ambitious agenda acknowledges universal access, more work is needed to ensure an equitable approach to SRHR–an approach that ensures that the needs and priorities of specific groups of people, who are persistently disadvantaged by existing systems of power, are not left behind.

Stigma and discrimination in healthcare settings

Stigma and discrimination manifest in broader society and in healthcare settings, and reflect levels and types of privilege, power, and disadvantage within society. Stigma and discrimination are related concepts with distinct differences [ 3 ]. Link and Phelan (2001) define stigma as the co-occurrence of “labeling, stereotyping, separation, status loss and discrimination” in contexts where power is exercised [ 4 ]. Discrimination, on the other hand, is defined as unfair and unjust actions towards an individual or group based on real or perceived status or attributes, medical conditions, socioeconomic status, gender, race, sexual identity, or age. Discrimination is a fundamental feature and expression of stigma, occurring both at the structural-level (societal conditions constraining opportunity or well-being) and individual-level (unequal or unfair treatment based on membership of a social group) [ 3 ]. Link and Phelan describe discrimination as the endpoint of the stigmatization process [ 4 ], while others view discrimination as a manifestation of the stigmatization process [ 5 ]. Both perspectives likewise place stigma and discrimination as fundamental causes of health inequities for three key reasons [ 3 , 6 , 7 ]: 1) stigma and discrimination influence several health outcomes through multiple pathways; 2) stigma and discrimination limit access to resources that can be used to avoid or minimize health risks or consequences; and 3) stigma and discrimination are related to health inequalities irrespective of time or place. Central to the conceptualization of stigma is the context and experience of power, privilege, and dominance that fosters environments of oppression and ‘othering’ of those who are stigmatized or discriminated against [ 8 , 9 ]. When stigma or discrimination is experienced in healthcare settings, it is a violation of human rights [ 10 , 11 ].

Stigma and discrimination are multi-level conditions that can differ across contexts, but there are common drivers, manifestations, and consequences present across settings and populations [ 12 ], including in healthcare settings. In Fig 1 , we depict a multi-level stigma model that reflects these complexities within SRHR settings, mapped across the levels of internalized stigma, perceived stigma, enacted stigma, structural stigma, and layered stigma [ 13 ]. Internalized stigma refers to when a person with certain attributes is aware of public stigma about their attributes, agrees with these stereotypes, and applies the stigma to themselves [ 13 ]. Perceived stigma reflects an individual’s awareness of public stigma or beliefs that others hold stigmatizing thoughts about their condition or group [ 14 , 15 ]. Enacted stigma refers to the manifestations of unfair treatment arising from adverse social judgment [ 16 ]. Structural stigma encompasses the societal conditions, sociocultural norms, and institutional policies that influence the opportunities and well-being of stigmatized groups [ 17 ].

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• PNG larger image
• TIFF original image

This figure depicts the complexities of where stigma and discrimination exist within sexual and reproductive health and rights, and the levels where it can be confronted. Footnote: i Internalized stigma: person with certain attributes is aware of public stigma about their attributes, agrees with these stereotypes, and applies the stigma to themselves [ 13 ] ii Perceived stigma: individual’s awareness of public stigma or beliefs that others hold stigmatizing thoughts about a condition [ 14 , 15 ] iii Enacted stigma: manifestations of unfair treatment arising from adverse social judgment [ 16 ] iv Structural stigma: societal conditions, sociocultural norms, and institutional policies that influence the opportunities and well-being of stigmatized groups [ 17 ] v Layered stigma: interaction between multiple stigmatized identities within an individual or group [ 18 ].

https://doi.org/10.1371/journal.pgph.0000582.g001

Reproductive justice, a movement led by women of color in the United States, strives to achieve health equity, end discrimination and oppression, and challenge medical hierarchies through the recognition that the intersectionality of social, political and economic identities shape peoples’ abilities to access safe, appropriate, and respectful SRHR services [ 19 , 20 ]. Through the lens of reproductive justice, we can better understand the intersecting influences of laws and social policies on people’s and communities’ health and well-being, and how these laws and policies contribute to longstanding injustices and structural oppression. Tantamount to achieving reproductive justice is acknowledging, then dismantling, oppressive systems that prohibit all people from achieving their fullest potential. Reproductive justice, therefore, can extend conceptualizations of stigma and discrimination from the interpersonal level, to better implicate the institutions and systems that perpetuate stigma and discrimination at the structural level. Similarly, global evidence has shown that women are mistreated during childbirth, which includes both structural and interpersonal discrimination while seeking care [ 21 ]. Eliminating stigma and discrimination within healthcare settings is critical to the attainment of reproductive justice and respectful care for all.

Structural and individual experiences or consequences of stigma and discrimination within sexual and reproductive healthcare have been well documented. Institutional and broader health system and social policies may drive stigma and discrimination in healthcare settings [ 12 ], where manifestations of stigma are both overt and covert [ 12 , 21 , 22 ]. Likewise, health workers’ perceptions, fears, belief systems, negative attitudes, moral distress, and lack of awareness about stigma, of a health condition, or the population may contribute to stigma in SRHR settings [ 12 ]. Individuals who are disadvantaged by systems of power and seeking sexual and reproductive health services may receive unfair or unequal treatment or have worse health outcomes compared to those who are in more privileged positions. Research has consistently shown that individuals who experience stigma and discrimination in healthcare settings may delay or forego seeking healthcare in the future [ 23 ]. Once individuals from stigmatized groups access the health system, they may be denied care or experience delays in receiving care. They may also be provided lower-quality care, receive care that is not culturally appropriate, or experience mistreatment such as discrimination, verbal and physical abuse, and denial of care [ 12 , 24 , 25 ]. Collectively, this can result in dissatisfaction and loss of trust in the health system, resulting in a vicious cycle of delaying care or not seeking care at all [ 26 ]. Additionally, it can lead to delayed diagnoses and initiation of care, as well as lower adherence and engagement in care, leading to poor health outcomes [ 27 , 28 ]. The experience of discrimination itself has profound impacts on people’s physical and mental health as well as their general wellbeing [ 29 – 31 ].

Layered stigma refers to the interaction between multiple stigmatized identities within an individual or group [ 18 ]. For example, in the United States, persistent disparities exist in maternal mortality where Black women are three times more likely to die than non-Hispanic white women, and these experiences occur within a history of racist reproductive policies [ 32 ]. These reproductive policies intentionally practiced non-consensual or involuntary sterilization on Black women as a way of limiting the population of the perceived inferior group [ 33 ], and are a clear representation of structural racism. In Australia, racist government policies forcibly removed babies and children from Aboriginal families as part of the white Australia ‘assimilation policy’, leading to profound intergenerational trauma, loss of identity, and grief [ 34 ]. During apartheid South Africa, the Afrikaner government racialized and weaponized family planning by providing tax incentives for white women to procreate, while simultaneously promoting contraception for Black and Coloured women to limit fertility [ 35 ]. Present-day disparities are likewise driven by racism, which manifests in various ways including Black and Indigenous women lacking access to sexual and reproductive services, abuse in health care settings, assaults on migrant women’s reproductive autonomy, including forced sterilizations in detention centers, and the ongoing stress of detrimental colonial processes and living in race-conscious societies [ 36 – 40 ].

Stigma and discrimination also drive inequities in sexual and reproductive outcomes based on people’s social status, including socioeconomic status, marital status, and age. Prior studies have shown women of low socioeconomic status (measured variably by household wealth, caste, education, literacy, and employment status) are more likely to have poorer experiences during childbirth than those of higher socioeconomic status [ 41 – 43 ]. A World Health Organization (WHO) study on the mistreatment of women during childbirth in Ghana, Guinea, Myanmar and, Nigeria showed that adolescents and younger women were twice as likely to be physically abused and four times as likely to be verbally abused during childbirth, compared to older women, and 3% of women reported experiencing stigma or discrimination [ 22 , 44 ]. Other forms of stigmatization based on gender and sexual orientation, disability, disease conditions such as HIV, STIs, tuberculosis, leprosy, substance use, and mental illness, as well as the type of care such as infertility and abortion services have been extensively documented as a barrier to care [ 24 , 26 , 41 , 45 – 47 ]. Furthermore, the use of certain health services can be stigmatizing in and of themselves (such as abortion, STI, and HIV services), and thus can result in stigma and discrimination of healthcare users, providers, and communities.

Strategies to reduce stigma and discrimination in healthcare settings

Given the multi-level drivers and manifestations of stigma and discrimination, sustainable and scalable strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings likely need to reflect this complexity. To date, much of the literature on strategies to reduce stigma and discrimination have been in the HIV field, with comparably less research on sexual and reproductive health. Nyblade and colleagues (2019) synthesized evidence on facility-based interventions to reduce stigma in HIV, mental illness, and substance abuse and identified six main approaches to reduce stigma broadly classified in Box 1 [ 12 ]. Many interventions identified had multiple components to reduce stigma [ 12 ], and the intervention mechanisms of action can be summarized as follows: improving healthcare provider awareness of stigma and contact with the stigmatized group may translate into improved practices of empathy in clinical encounters. Training healthcare providers on concrete tools and approaches to address stigma and work with stigmatized groups transforms abstract theories of stigma into concrete action in how they can provide better care. Policy reform may create more enabling environments for safe, respectful, inclusive, and anti-racist care without creating further barriers to certain groups seeking care. Lastly, strengths-based and community-driven approaches can empower individuals and groups who experience social, cultural, and economic oppression to achieve their SRHR by drawing on their own strengths and assets to lead initiatives or programs to tackle stigma and discrimination.

Box 1. Six approaches to reduce stigma and discrimination in healthcare settings.

This figure six approaches to reduce stigma and discrimination in healthcare settings (adapted from Nyblade and colleagues [ 12 ]).

• Provision of information to teach healthcare providers about health conditions, or stigma manifestations and consequences
• Skills-building for healthcare providers to improve competence in working with a stigmatized group
• Participatory learning for either/both healthcare providers and healthcare users to engage in the intervention
• Contact with stigmatized groups to humanize the stigmatized group and encourage healthcare providers to develop empathy
• Empowerment approach to improve healthcare user coping mechanisms to overcome stigma
• Structural or policy reform to improve or create redress mechanisms, or facility restructuring

While perceptions, experiences and impacts of stigma and discrimination in health have been increasingly well-documented, a critical gap remains in understanding the evidence on strategies to reduce stigma and discrimination in sexual and reproductive healthcare. We aim to address this gap by conducting a systematic review of strategies (inclusive of interventions, programs, and policies) to reduce stigma and discrimination in sexual and reproductive healthcare settings, in order to describe types and characteristics of strategies, assess effectiveness, and synthesize key stakeholder experience and perceptions of the strategies.

This is a mixed-methods systematic review and narrative synthesis of strategies to reduce stigma and discrimination in sexual and reproductive healthcare services globally. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 48 ] ( S1 Table ), Cochrane Effective Practice and Organisation of Care guidance [ 49 ], and the protocol is available ( S1 Text ) and registered on the International prospective register of systematic reviews ((PROSPERO): CRD42020221054).

Types of studies

For the quantitative component, randomized and non-randomized trials, pre-post studies (with or without a control group), interrupted time series, and other designs that compare the strategy to reduce discrimination with usual care were eligible for inclusion. Our operational definition of what constitutes a ‘strategy’ was inclusive of approaches such as policy reform, introducing new models of care, healthcare provider training (workshops, sensitization training, simulation), mystery clients, and community-based approaches targeting healthcare users. Studies published in abstract form were not eligible for inclusion, unless additional information could be obtained from study authors. Where we identified study protocols, we forward-reference searched to identify any results publications for relevance. We included studies that focused on strategies with the following characteristics: 1) studies that directly aimed to reduce stigma or discrimination in SRHR, or reducing inequity or promoting equity by reducing stigma and discrimination in SRHR; 2) studies that included a quantitative outcome related to SRHR and stigma or discrimination (e.g. experiences of stigma or discrimination, provider perceptions of stigma and discrimination); and 3) strategies that targeted healthcare users or communities, providers, health facilities or systems, health laws, or policies.

For the qualitative component, primary studies that used qualitative or mixed-methods designs to evaluate user or provider experiences of strategies to reduce stigma or discrimination were eligible for inclusion (e.g. process evaluations, ethnographies, case studies, phenomenological studies). Studies were eligible for inclusion regardless of whether they were conducted alongside studies of effectiveness (sibling studies) and did not need to have a comparison group to be eligible.

Topics of interest, types of participants, and settings

• Maternal health services , including preconception care (pregnancy and infertility testing, counselling, and services), antenatal care (including STI screening and treatment, and preventing mother-to-child transmission of HIV (PMTCT)), childbirth care, and postpartum mother and baby care up to six weeks after birth (including immunization, breastfeeding)
• Contraceptive counselling and services , including STI screening
• Safe abortion and post-abortion services
• Reproductive tract cancers including cervical cancer counselling and services
• Gender-based violence screening
• Infertility testing and treatment

We excluded STI and HIV counseling, testing, and treatment services if conducted outside the context of contraceptive or maternal health services, as these topics have been well documented in the literature [ 12 , 27 , 28 ]. We excluded ‘comprehensive sexuality education’ as this is typically delivered in school-based settings, and the setting of interest in this review is healthcare settings. We adopted an intersectional approach to understanding discrimination by including studies that explore discrimination based on (but not limited to) race, ethnicity, Indigenous identity, social status, gender, sexuality, dis(ability), age, religion, migration or visa status, and the intersections between these identities.

Studies that included perspectives of healthcare users, family members of healthcare users, community members, healthcare providers, policy-makers, or other key stakeholders were eligible for inclusion, with no restrictions to sociodemographic characteristics or identity. Studies conducted in any country globally, and in any type of setting where sexual and reproductive healthcare is received (e.g. health facilities, community-based care, home-based care, or other types of institutional-based care) were eligible.

Search methods and study selection

We searched the following databases from inception to date of search, without any limits on language or publication date ( S2 Text ): MEDLINE (April 6, 2022), CINAHL (March 29, 2022), and Global Health Ovid (April 13, 2022). In addition to database searching, we reviewed the reference lists of included studies, conducted a forward citation search of all included studies using Web of Science, and conducted a grey literature search using OpenGrey ( www.opengrey.eu ). We collated all citations identified from different searches into Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia, www.covidence.org ) and removed duplicates. Two review authors independently assessed each record for potential eligibility, and excluded references that did not meet the eligibility criteria (MAB, PAA, MVC, OJO, ANW). Two independent reviewers assessed full texts of potentially eligible studies, and disagreements were resolved through discussion and consensus with a third reviewer (MAB, PAA, MVC, OJO, ANW). For title and abstract assessment of studies published in languages that none of the review team are fluent in (languages other than English, Spanish, or French), we carried out initial translation through Google Translate. If the translation indicated agreement with the inclusion criteria, or if the translation is insufficient to decide, we consulted other colleagues in our networks to assist in assessing full text for inclusion.

Data extraction and critical appraisal

We designed a data extraction form for this review to extract data on study setting, sample characteristics, objectives, guiding frameworks, study design, strategy design and components, data collection tools and analysis methods, and author conclusions. For quantitative studies, we extracted data on the outcomes of interest related to discrimination (e.g. percentages, odds ratios, relative risks, prevalence estimates). For qualitative studies, we extracted the qualitative findings including author themes and participant quotations. Two independent reviewers critically appraised the methodological limitations of included studies using the Cochrane ROBINS-I tool [ 50 ] for quantitative studies and an adaptation of the Critical Appraisal Skills Programme (CASP) tool ( www.casp-ul.net ) for qualitative studies (MAB, PAA, MVC). Disagreements were resolved through discussion or involving a third review author where necessary.

Data management, analysis and synthesis

We used a narrative synthesis approach, which is a particularly useful approach when analyzing data from different types of studies [ 51 ]. A narrative synthesis approach focuses on the interpretive synthesis of the narrative findings of the research to sort and analyze studies into more homogenous groups based on critical components such as study design, study setting, program components, types of participants, type of health service and health topic, types of outcome, and direction or magnitude of effect [ 51 ]. There are four key elements of narrative synthesis recommended for implementation-focused narrative reviews, and these elements are analyzed iteratively throughout the review and synthesis process [ 51 ]. First, we developed a preliminary synthesis, which consisted of an initial textual descriptive analysis of included intervention studies and their findings. This preliminary synthesis allowed us to identify and evaluate initial factors, components, and processes that affected the construction of analytic outputs from the subsequent analysis steps. We used this textual descriptive analysis to group and cluster extracted data based on similar features, such as type of strategy, study location, and context, whether the strategy was designed with or by the stigmatized group, and type of participants ( Table 1 ). Second, we explored the relationships between and across studies to understand how critical study design and intervention design factors may have influenced the likelihood of implementation success. Key relationships of interest included the relationships between study designs, levels of engagement, and magnitude and directionality of key findings ( Table 2 ). Third, we used a thematic analysis approach [ 52 ] to synthesize the qualitative evidence of key stakeholder perspectives and experiences of the strategies. This included line-by-line coding of findings from primary studies and organization into descriptive and analytic themes and interpretations [ 53 ]. Fourth, we developed a model to map the strategy aims and outcome measurement across the different levels where stigma can be confronted, reflected in Fig 3. We assessed the robustness of the synthesis using multiple iterative methods to reflect on the methodological quality of the primary studies included in the synthesis and the trustworthiness of our analysis [ 51 ]. As described above, we assessed the methodological limitations of included studies using different tools appropriate for different study designs, and considered throughout the analysis process how to minimize bias, for example by ensuring that studies of equal technical quality are given equal weighting, and by clearly stating eligibility criteria across each step of the review ( S2 and S3 Tables).

https://doi.org/10.1371/journal.pgph.0000582.t001

https://doi.org/10.1371/journal.pgph.0000582.t002

Throughout all stages of this review, we practiced critical reflexivity both as individuals and as a review team, which contributed to improving the robustness of the synthesis. This enabled us to consider, acknowledge and reflect on how our own lived experiences, employment, training, perspectives on discrimination and sexual and reproductive health services, and other factors shaped and influenced how we designed and conducted the review, synthesized, and interpreted the findings. We noted at the start of this review that the strength of our team comes from our own diversity: we have professional expertise and experience in sexual and reproductive health, public health, social sciences, medicine, obstetrics, epidemiology, social and reproductive justice, global health, and First Nations health. We are from different racial, ethnic, and religious backgrounds, and some of us are first- or second-generation migrants. We currently work at academic institutions, and at organizations that provide patient and community care in high-resource settings, and our projects regularly engage with people who are disadvantaged by existing systems of power at both global and local levels.

Out of 8,262 articles screened, 12 articles from 10 studies met inclusion criteria (three articles were from one study [ 54 – 56 ]). Fig 2 presents the PRISMA diagram of inclusions.

This figure depicts the PRISMA flow diagram, detailing the database searches, number of abstracts and full texts screened, reasons for exclusion, and included studies and articles.

https://doi.org/10.1371/journal.pgph.0000582.g002

Description of included studies

Table 1 describes the characteristics of included studies. Half of the included articles (6/12) were conducted in the United States [ 54 – 59 ], one study conducted in each of Bangladesh [ 60 ], Canada [ 61 ], South Africa [ 62 ], United Kingdom [ 63 ], and Zambia [ 64 ], and one multi-country study conducted in three sub-Saharan African and three Latin American countries (countries not specified) [ 65 ]. Despite no date limits on the search, all included articles were published between 2003 and 2020. The topics within sexual and reproductive health varied substantially in the included articles: five were on abortion [ 54 – 57 , 65 ], two on sexual health and HIV [ 60 , 62 ], and one each on pregnant women with substance abuse [ 58 ], PMTCT [ 64 ], sexual health [ 59 ], sexual health, substance abuse, and STIs and blood-borne infections [ 61 ], and genitourinary medicine, family planning, and women’s health [ 63 ]. Most articles (8/12) collected data from participants who were health and/or social workers [ 54 – 56 , 58 , 59 , 61 , 62 , 65 ]; three articles included both health workers and healthcare users [ 60 , 63 , 64 ], and one article included only healthcare users (women who had abortions) [ 57 ]. Six of 12 included articles described only quantitative results [ 55 , 58 , 60 , 61 , 64 , 65 ], three were qualitative evaluations of strategies [ 54 , 56 , 57 ], and three were mixed-methods evaluations of strategies [ 59 , 62 , 63 ]. Among the articles that included quantitative measures, one was a cluster randomized controlled trial [ 64 ], and the remaining articles used quasi-experimental designs, including six articles using a pre-test, post-test single group design [ 55 , 59 , 60 , 62 , 63 , 65 ], and two articles used a post-test only design [ 58 , 61 ]. We used the ROBINS-I tool to assess the risk of bias in the quantitative studies ( S2 Table outlines detailed critical appraisal). Most (8/9) studies had an overall critical risk of bias, primarily due to bias from confounding (typically due to no control group or adjustment for potential confounders), selection of participants (typically due to self-selection into the intervention group), bias due to missing data (substantial loss to follow-up or blank surveys) and measurement of outcomes (typically because participants who knew they were in the intervention group reported the impact of the intervention on their knowledge or behavior). One study had a serious risk of bias due to deviations from intended interventions, missing data, and measurement of outcomes. We used an adaptation of the CASP tool to assess methodological limitations in qualitative studies ( S3 Table ). These studies had minor to moderate concerns, due to limitations in data collection, reflexivity, and data analysis.

Narrative synthesis

Description of interventions..

Table 2 describes the characteristics of the included strategies, using an adaptation of Nyblade and colleagues approach for categorizing approaches to reduce stigma and discrimination [ 12 ]. Of the 10 strategies (Harris et al., 2011, Martin et al., 2014, and Debbink et al., 2016 evaluated the same strategy), most (7/10) provided information to healthcare providers about health conditions affecting the stigmatized population or discrimination experienced by this group [ 57 – 64 ]. Six out of 10 strategies aimed to build skills or improve the competence of providers working with a stigmatized group (as defined by the researchers) [ 58 – 64 ]. Four out of ten strategies were participatory and designed with or by the stigmatized group [ 55 , 59 , 61 , 65 ]. Three strategies involved engagement or contact with the stigmatized group as part of the strategy [ 55 , 59 , 65 ]. Four strategies used empowerment approaches to help improve coping mechanisms to overcome stigma (such as empowering stigmatized groups–including abortion providers–with knowledge and skills) [ 55 , 57 , 64 , 65 ], and three strategies included structural or policy reform (such as integrating health services or changing models of care) [ 59 , 63 , 64 ]. Half of the strategies had repeated components, such as multiple workshops (off-site or online, followed by on-site, or follow-up monitoring or technical assistance) [ 55 , 59 – 61 , 64 ], and the remaining were once-off workshops [ 57 , 58 , 62 , 63 , 65 ].

Quantitative evaluation of impact.

Fig 3 describes the quantitative measurement approaches and outcome evaluation among the nine articles with quantitative outcomes. All articles measured health worker-reported outcomes [ 54 , 55 , 58 – 61 , 63 – 65 ]. Three articles measured both health worker-reported and client-reported outcomes [ 60 , 63 , 64 ]. Four articles used validated measurement tools [ 55 , 60 , 64 , 65 ]. One study also reported retention in care at 12 months for babies with mothers living with HIV [ 64 ].

This figure presents the characteristics of included interventions, mapped to the six main strategies to reduce stigma identified by Nyblade and colleagues [ 45 ].

https://doi.org/10.1371/journal.pgph.0000582.g003

Given the heterogeneity in outcome measurement (e.g. different tools, scales and measurement approaches) and evaluation (e.g. reporting percentages, means, odds ratios, and beta-coefficients), meta-analysis was not possible. Fig 3 narratively reports the impact of the interventions on the relevant outcomes of interest. In general, strategies that gave providers information about health conditions and/or stigma among the population group of interest reported increased self-reported awareness of the challenges faced by and decreased assumptions made about the population group. However, there were limitations in whether newfound knowledge was translated into changed practice or improved confidence in caring for population groups of interest, as these outcomes were typically not measured or reported by either providers or users. Of the three articles that evaluated user-experiences after the intervention [ 60 , 63 , 64 ], there were mixed results on the impact of the strategy on their experiences of care. In client exit interviews, Geibel and colleagues found that healthcare users were more likely to discuss being a member of a key population group and disclosing sexual activity to providers, and less likely to report the provider acted in a discriminatory way [ 60 ]. Phiri and colleagues found that women living with HIV were more likely to report social support and reduced perceived stigma from healthcare workers, despite no effect on retention of their babies in care at six or twelve months [ 64 ]. Kinn and colleagues found that service integration increased perceived confidentiality and happiness with overall care, but had no effect on the quality or availability of services [ 63 ]. Of note, the three articles that evaluated user experiences after the intervention collected data at two and six months after intervention [ 64 ], six months after the intervention [ 63 ], and six and twelve months after the intervention [ 60 ], which limits the evaluation of the sustainability of the intervention effects over time.

Qualitative evaluation of impact.

Six articles contributed qualitative evidence (including qualitative evidence from three mixed-methods studies) related to stigma and discrimination in abortion care, sexual health, and service integration [ 54 , 56 , 57 , 59 , 62 , 63 ]. One article with qualitative evidence following implementation was from the perspective of women who had had an abortion [ 57 ], four articles were from the perspective of health workers after implementation [ 54 , 56 , 59 , 62 ], and one article was from the perspective of health workers before and after implementation [ 63 ].

Three articles described two strategies (introducing a culture of support for abortion patients [ 57 ] and the Providers Share Workshop [ 54 , 56 ]) that aimed to address internalized stigma among women who had abortions and abortion care providers. Both strategies were viewed positively, and perceived by participants to be validating, supportive, and contributed to “feeling understood” and less alone [ 54 , 56 , 57 ]. While the strategies took different forms (reflexive workshops [ 54 , 56 ], educational information in a film, and brochure [ 59 ]), participants reflected that the materials helped them to realize that they could openly discuss their feelings of stigmatization with others. Abortion providers felt that the workshops engendered an ‘ esprit de corps’ [collective spirit] that helped them to manage the consequences of feeling stigmatized through the safe exchange of ideas [ 54 , 56 ].

Two articles described strategies that aimed to address perceived and enacted stigma among healthcare providers working with stigmatized groups (youth who identify as gender non-binary and/or do not identify as heterosexual) [ 59 ] and men who have sex with men, sex workers and people who use drugs [ 62 ]). Healthcare providers described that the interventions encouraged introspection and cultural humility to confront their own prejudices, and increased their empathy and compassion to the stigmatized groups, as well as improved their understanding of stigma and marginalization [ 59 , 62 ]. However, there was no discussion on whether their changed attitudes led to meaningful change in clinical encounters.

One study described the impact of a strategy to address structural stigma through the introduction of integrated services [ 63 ]. Healthcare providers felt that the integrated services reduced the stigma associated with attending sexual health services, and perceived the integration as beneficial to healthcare users [ 63 ].

Mapping interventions and outcome measurement to the levels at which stigma exists and can be confronted.

Fig 4 maps the nine studies with relevant quantitative outcomes on stigma or discrimination to the different levels at which stigma can exist and be confronted. First, we mapped the studies based on which level or levels of stigma (internalized, perceived, enacted, structural, layered) the strategies aimed to address and how they were measured (Tables 1 and 2 ). Where strategies aimed to address or measure across more than one level of stigma, we indicated as such. Then we visually mapped the strategy aims and measurement approaches across the different levels of stigma to explore where the aims and measurement approaches were similar and different.

This figure depicts a mapping of the nine studies with relevant quantitative outcomes on stigma or discrimination to the different levels at which stigma can exist and be confronted. First, we mapped the studies based on which level or levels of stigma (internalized, perceived, enacted, structural, layered) the strategies aimed to address and how they were measured (Tables 1 and 2 ). Where strategies aimed to address or measure across more than one level of stigma, we indicated as such. Then we visually mapped the strategy aims and measurement approaches across the different levels of stigma to explore where the aims and measurement approaches were similar and different.

https://doi.org/10.1371/journal.pgph.0000582.g004

Four articles (4/9) aimed to intervene and measured within the same level of stigma [ 55 , 60 , 62 , 65 ]: Martin et al. 2014 and Mosley et al. 2020 both aimed to address and measured internalized stigma among abortion providers; Duby et al. 2019 aimed to address and measure perceived stigma among health workers and service users (sexual health); and Geibel et al. 2017 aimed to address and measure perceived and enacted stigma among health workers and service users (youth SRHR).

Five articles (5/9) had differences in the levels of stigma that the strategy aimed to intervene on, and the measurement approaches used [ 58 , 59 , 61 , 63 , 64 ]. These articles all aimed to address higher levels of stigma (structural and/or enacted stigma), but measured more proximal levels of stigma. For instance, Kinn 2003 aimed to address structural stigma by reconfiguring health services and measured the impact of service reconfiguration on perceived and enacted stigma [ 63 ]. Similarly, Jadwin-Cakmak aimed to address structural, enacted, and perceived stigma in sexual healthcare for gender- and sexuality-diverse youth after training workshops, and measured the impact on enacted and perceived stigma [ 59 ].

We identified 12 articles from 10 studies with strategies to reduce stigma and discrimination in SRHR settings. Our review highlights several critical gaps and opportunities in the literature, which are discussed below, including: 1) focus on describing the problem of stigma and discrimination but not intervening to address it; 2) strategies that aim to improve equity, access, or quality of care for marginalized groups, but do not address stigma and discrimination, and 3) strategies that focus on healthcare users’ and providers’ internalized, perceived, or enacted stigma, but ignore the structural and societal conditions that perpetuate stigma and discrimination.

While there is a substantial body of literature describing and measuring various types of stigma and discrimination experienced by people seeking care for sexual and reproductive health [ 66 – 69 ], there is very limited interventional work to reduce stigma and discrimination. In our review, we were ultimately only able to identify 12 articles from 10 studies that met our criteria for intervening to address these factors for sexual and reproductive health care. Our findings highlight that despite strong descriptive evidence of stigma and discrimination in healthcare settings, we have only just begun to use that evidence to design and evaluate strategies to address stigma and discrimination (which is further supported by the years of publication of included studies 2003–2020). We hypothesize three potential reasons for this critical gap. First, stigma and discrimination may be perceived as particularly challenging to address as they touch on potentially deeply rooted biases, so people are hesitant to try. Second, it is possible that researchers and implementers do not have a good framework to think through what types of strategies are likely to have the most effect. Third, power dynamics in funding and health leadership may have historically limited research and funding to address the impact of stigma and discrimination in healthcare settings. People with lived and professional experiences of stigma and discrimination may often not be in the position to implement the change they envision. They are thus often compelled to design studies to educate those in power on the magnitude and effect of the problem. This is reflected in the preponderance of descriptive work, with limited interventional work. More research is urgently needed to develop and test different strategies to address the persistent problem of stigma and discrimination in healthcare settings.

Our findings are consistent with previous systematic reviews on strategies to address stigma and discrimination in maternal and child health, which found limited publications on the topic [ 5 ]. This may be because maternal and child health may comparatively not be considered stigmatized health areas. In contrast, systematic reviews on strategies that focus on stigmatized health conditions tend to yield more publications; for example, Nyblade and colleagues’ systematic review on stigma in health facilities identified forty-two studies focusing on strategies to reduce HIV, mental illness, and substance abuse stigma [ 45 ]. Most strategies focused on reducing HIV-related stigma in healthcare settings [ 12 , 70 ]. However, given how much has been written on describing HIV-related stigma and discrimination, it is surprising that a recent systematic review of quantitative studies (with comparative designs) of strategies to reduce HIV-related stigma and discrimination in healthcare settings found only 14 eligible papers reporting on eight studies [ 70 ]. Nayar and colleagues note that even with the HIV literature, there are no published studies on the effect of stigma-reduction strategies for pregnant women living with HIV or the direct impact of HIV-related stigma on the uptake of PMTCT services [ 5 ]. Similarly, studies of strategies that target stigma and discrimination as a means to improve neonatal survival and health are nearly nonexistent, except in the PMTCT literature, where strategies have focused on eliminating barriers to care among pregnant women living with HIV [ 42 ]. The dearth of research exploring and evaluating the impacts of strategies to reduce stigma and discrimination in healthcare settings, using rigorous design and evaluation methods to measure impact, is a critical gap identified in our review.

Another critical gap we identified is how many strategies aim to improve the health and well-being of marginalized groups, but do not measure stigma and discrimination outcomes. For example, our initial screening yielded several publications based on the Janani Suraksha Yojana (JSY) scheme—a conditional cash transfer program in India that incentivizes women to give birth in a health facility as a way to reduce maternal and neonatal mortality [ 71 , 72 ]. However, all of these studies were ultimately excluded because, although this program was intended to reduce inequities and improve access, none measured stigma or discrimination as outcomes. Other studies included interventions to improve access through voucher programs, or mobile or special clinics for marginalized groups [ 73 – 76 ], which likewise did not measure stigma and discrimination as outcomes. This is important to note because these interventions, although well intended, could further lead to stigmatization of marginalized groups if not designed intentionally to reduce stigma and discrimination.

We also identified a lack of a comprehensive examination of specific types of stigma and multiple stigmas experienced. Most studies included in our review focused on internalized, perceived, or enacted stigma. While three studies attempted to address structural stigma [ 59 , 63 , 64 ], including through the integration of health services or changing models of care, only one study actually measured structural stigma [ 64 ]. This highlights the challenges in the measurement of different levels of stigma, particularly structural and layered stigma, which operates at higher and across multiple levels. While it is critical to identify specific strategies to address individual levels of stigma, a layered approach is needed to truly address health equity and to recognize the intersectional oppressions at play across multiple marginalized and stigmatized groups. Moreover, focusing on lower-level stigmas, such as internalized stigma or perceived stigma, places responsibility on individuals (healthcare users and providers) to address issues of stigma and discrimination, and overlooks systemic and organizational drivers. Indeed, most strategies focused on educating providers while others involved healthcare users themselves in the development of strategies. While centering user experiences is important to develop culturally-appropriate strategies, health system management and policymakers also have an important role to play in addressing underlying societal power inequities [ 77 ]. Most studies focused on stigmas related to health conditions—such as abortion stigma or SRH stigma—failing to highlight the underlying social conditions that drive stigma and discrimination, such as classism, racism, ableism, and xenophobia. The patient-provider relationship, as well as the experiences of healthcare users are, however, often a reflection of deeper dynamics of power inequities in societies in which they are embedded [ 77 ]. This includes the subordination of certain racial groups, women’s subordinate position to men, and the marginalization of specific populations such as LGBTQ+, those with disabilities, and so on. A greater emphasis on how to address stigma and discrimination that stems from inequities in health systems, social and economic policies, community social norms, and power differentials at the societal level is critical in addressing stigma and discrimination in the healthcare setting.

Strengths and limitations

Our review has several limitations. We excluded strategies that aimed to increase access to health services (such as policy-level abortion reform, and increasing access to facility-based birth), unless stigma or discrimination was an outcome measure. While this may have excluded some structural interventions that could potentially address discrimination related to societal conditions that constrain opportunity or well-being, we note that increasing access alone does not necessarily equate to a reduction in stigma or discrimination. We also excluded strategies that did not aim to reduce stigma or discrimination, but may have unintentionally reduced stigma or discrimination, for example, strategies to improve person-centered care. Given the complexity of addressing stigma, we believe that effective strategies should explicitly aim to reduce stigma and discrimination and measure the impact of the strategy on stigma and discrimination-related outcomes. Our review also has several notable strengths. Finally, we explored how we could assess the differences in intervention effects based on the “doses” of the intervention (once-off, or repeat). However, we found that due to the heterogeneity in outcomes reported, and multiple (and often many) outcomes reported in the quantitative studies, we are unable to conclude anything meaningful about the impact of a once-off versus repeat training on outcomes of interest. We hypothesize that given the complexity of addressing stigma and discrimination, a once-off training would be less likely to evoke change (especially sustainable change), and that measurement of this in the included studies is limited by evaluation of intervention impact typically occurring close to the time of the intervention. This may be particularly true for interventions targeting areas other than increasing provider awareness, which we hypothesize would be likely to need repeat and sustained engagement with stakeholders to influence systems change.

We used a systematic review approach, which increases the credibility, reliability, and transparency of the findings. Our broad inclusion criteria for types of strategies and types of studies (quantitative, qualitative, and mixed-methods) also ensured we captured the range of studies relevant to the topic. Our international team of researchers has broad and complementary experience across public health, clinical practice, and social and reproductive justice that enriched the quality and scope of the review.

Implications for policy and practice

The findings from this review have important implications for policy and practice. Individuals who experience stigma and discrimination when accessing sexual and reproductive health care are at risk of harm and poor health outcomes. But beyond that, it is a violation of their human rights. Thus, strategies are urgently needed to eliminate stigma and discrimination in SRHR settings. In designing, implementing, monitoring, and evaluating interventions to reduce stigma and discrimination, it is essential that the views of the group or community experiencing stigma and discrimination are incorporated. Ideally, such interventions should be led or co-led by representatives from the particular group or community [ 78 ], to ensure that their needs and experiences are addressed. We note that while the inspiration for this review stemmed from our work on mistreatment during childbirth and respectful care, we did not identify any strategies to promote respectful care or reduce mistreatment during childbirth that explicitly included strategies to eliminate stigma and discrimination. Moving forward, we encourage researchers, programmers, and policy-makers to ensure that this critical component of respectful care is not neglected.

Health care providers need to be supported to undertake appropriate education and training to understand and overcome discriminatory care practices. However, training health care providers in and of itself is not enough to drive change [ 8 ]. Health services need to enact structural and policy reform to create safe, inclusive, and respectful environments for people both providing and accessing SRH services. In some instances, stigma and discrimination can affect both the healthcare users and providers of sexual and reproductive health care, as can occur with abortion care [ 79 ]. As such, it is likely that effective interventions will be complex, operating across multiple levels to maximize the likelihood for change.

Interventions that address stigma and discrimination across all layers, especially at the enacted and structural levels are lacking. It is at this societal and political level where enabling legal and policy contexts and social norms can strongly influence the care provided and received by people accessing SRH services. Efforts to reduce legal restrictions and drive broader social and cultural change can have an impact at an individual, community, and institution level. Activists can also play a major role in not only encouraging community awareness, but also policy change. These broader societal, cultural, and legal shifts can have a significant influence on health care providers, influencing decision making, referral processes, and care provided.

Conclusions

While important foundational work has been done to describe and define stigma and discrimination in sexual and reproductive healthcare settings, more work is urgently needed to intervene to eliminate stigma and discrimination in these settings, to achieve respectful, person-centered, and equitable care for all. Moreover, healthcare and policy interventions that aim to improve equity should consider measuring stigma and discrimination-related outcomes, as equity cannot be achieved when stigma and discrimination persist. While some work has been done to address perceived and enacted stigma, more work is needed to address structural and layered stigma to challenge and dismantle the societal conditions, sociocultural norms, and institutional policies that influence the opportunities and well-being of stigmatized groups. Provision of sexual and reproductive healthcare free of stigma and discrimination is a basic and essential tenet of every health system. The Sustainable Development Goals related to sexual and reproductive health targets will therefore not be achieved until health systems ensure people have access to sexual and reproductive healthcare free of stigma and discrimination.

Supporting information

S1 table. prisma checklist..

https://doi.org/10.1371/journal.pgph.0000582.s001

S2 Table. Risk of bias assessments for quantitative studies (ROBINS-I).

https://doi.org/10.1371/journal.pgph.0000582.s002

S3 Table. Critical appraisal of qualitative studies (CASP).

https://doi.org/10.1371/journal.pgph.0000582.s003

S1 Text. Review protocol.

https://doi.org/10.1371/journal.pgph.0000582.s004

S2 Text. Search strategies: Medline, CINAHL, Global Health.

https://doi.org/10.1371/journal.pgph.0000582.s005

Acknowledgments

Thank you to Rio With all for their support in designing the multi-level stigma models in Figs 1 and 3 , and to Patrick Condon for his assistance with the search update.

We appreciate the valuable contributions from the WHO working group on interventions to reduce mistreatment of women during childbirth: Gita Sen, Aditi Iyer, Bhavya Reddy, Sophia Thomas, Ravi Sadhu, Klaartje Olde Loohuis, Joyce Browne, Winter Bruner, Annemoon Jonker, Emmanuela Salia, Hannah Brown Amoakoh, Mary Amoakoh-Coleman, Bregje de Kok, Sasha Kruger, Rick Grobbee, Özge Tunçalp, Hedieh Mehrtash, Anayda Portela, Emmanuel Srofeneyoh, Kwame Adu Bonsaffoh, Soo Downe, Rebecca Nowland, Alan Farrier, Cath Harris, Lisa Tanyaradzwa Gondo, Kenny Finlayson, Gill Thomson, Carol Kingdon, Andy Clegg, Lynn Freedman, Marta Schaaf, and Maayan Jaffe.

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Stigma, prejudice and discrimination in global public health

2012, Cadernos de saúde pública

This article reviews the development of international research on the relationship between discrimination and health. It provides an overview of theoretical and empirical work on stigma and prejudice and their impact on discrimination and health. It argues that the literature on these issues has drawn primarily from social psychology and has focused on the impact of attitudes associated with stigma and prejudice on discriminatory practices and consequently health outcomes. It also identifies a growing trend in recent research towards a reconceptualization of stigma, prejudice and discrimination from the perspective of social inequality and structural violence, highlighting relations of power and exclusion that reinforce vulnerability within a complex social and political process. It concludes by briefly examining the ways in which this reconceptualization of discriminatory practices has generated a growing interest in the linkages between health and human rights and renewed interest...

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Migration Stigma : Understanding Prejudice, Discrimination, and Exclusion

Lawrence H. Yang is Professor of Social and Behavioral Sciences and Interim Chair of the Department of Social and Behavioral Sciences at New York University, where he is also Founding Director of the Global Mental Health and Stigma Program.

Maureen A. Eger is Associate Professor of Sociology at Umeå University.

Bruce G. Link is Distinguished Professor of Public Policy and Sociology at the University of California Riverside where he serves as Co-PI of the Health Disparities Research Center.

An introduction to the concept of “migration stigma,” along with new analytical frameworks to deepen understanding of the experiences of immigrants, their descendants, and native-born residents in immigrant-receiving societies.

Due to economic crises, sociopolitical instability, and climate change, international migration is likely to persist if not increase in the future. Meanwhile, struggles to secure widespread acceptance of immigrant populations are evident worldwide. This volume, edited by Lawrence Yang, Maureen Eger, and Bruce Link, introduces the concept of “migration stigma” and proposes new ways to understand the complex challenges facing immigrants, their descendants, and contemporary societies. Contributions reveal how migration stigma affects areas such as health, financial well-being, and social cohesion; analyze the multilevel and temporal processes underlying migration stigma; and propose social, economic, and policy frameworks to address its harmful consequences.

Contributors Muna Adem, Drew Blasco, Andrea Bohman, Heide Castañeda, Christian S. Czymara, Joerg Dollmann, Maureen A. Eger, Tyrone A. Forman, Daniel Gabrielsson, San Juanita García, Anastasia Gorodzeisky, Mark L. Hatzenbuehler, Marc Helbling, Mikael Hjerm, Seth M. Holmes, Elisabeth Ivarsflaten, Tomás R. Jiménez, Irena Kogan, Christian Albrekt Larsen, Bruce G. Link, Rahsaan Maxwell, Supriya Misra, Dina Okamoto, John E. Pachankis, Nicolas Rüsch, Georg Schomerus, Patrick Simon, Anders Vassenden, Paolo Velásquez, Katie Wang, Markus Weißmann, Rima Wilkes, Lawrence H. Yang, Min Zhou

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Migration Stigma : Understanding Prejudice, Discrimination, and Exclusion Edited by: Lawrence H. Yang, Maureen A. Eger, Bruce G. Link https://doi.org/10.7551/mitpress/15529.001.0001 ISBN (electronic): 9780262378833 Publisher: The MIT Press Published: 2024

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Table of Contents

• [ Front Matter ] Doi: https://doi.org/10.7551/mitpress/15529.003.0001 Open the PDF Link PDF for [ Front Matter ] in another window
• List of Contributors Doi: https://doi.org/10.7551/mitpress/15529.003.0002 Open the PDF Link PDF for List of Contributors in another window
• Preface By Julia R. Lupp Julia R. Lupp Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0003 Open the PDF Link PDF for Preface in another window
• 1: Migration Stigma: An Introduction By Lawrence H. Yang , Lawrence H. Yang Search for other works by this author on: This Site Google Scholar Maureen A. Eger , Maureen A. Eger Search for other works by this author on: This Site Google Scholar Bruce G. Link Bruce G. Link Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0004 Open the PDF Link PDF for 1: Migration Stigma: An Introduction in another window
• 2: How Are Stigma Processes Related to Different Aspects of Migration-Generated Diversity? By Drew Blasco , Drew Blasco Search for other works by this author on: This Site Google Scholar Bruce G. Link , Bruce G. Link Search for other works by this author on: This Site Google Scholar Andrea Bohman , Andrea Bohman Search for other works by this author on: This Site Google Scholar Tyrone A. Forman , Tyrone A. Forman Search for other works by this author on: This Site Google Scholar Anastasia Gorodzeisky , Anastasia Gorodzeisky Search for other works by this author on: This Site Google Scholar John E. Pachankis , John E. Pachankis Search for other works by this author on: This Site Google Scholar Georg Schomerus , Georg Schomerus Search for other works by this author on: This Site Google Scholar Lawrence H. Yang Lawrence H. Yang Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0005 Open the PDF Link PDF for 2: How Are Stigma Processes Related to Different Aspects of Migration-Generated Diversity? in another window
• 3: Revisiting Group Threat Theory Using Insights from Stigma Research By Andrea Bohman , Andrea Bohman Search for other works by this author on: This Site Google Scholar Maureen A. Eger , Maureen A. Eger Search for other works by this author on: This Site Google Scholar Daniel Gabrielsson , Daniel Gabrielsson Search for other works by this author on: This Site Google Scholar Paolo Velásquez Paolo Velásquez Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0006 Open the PDF Link PDF for 3: Revisiting Group Threat Theory Using Insights from Stigma Research in another window
• 4: The Conceptualizations, Causes, and Consequences of Stigma: Background for a Model of Migration-Generated Stigma By John E. Pachankis , John E. Pachankis Search for other works by this author on: This Site Google Scholar Katie Wang Katie Wang Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0007 Open the PDF Link PDF for 4: The Conceptualizations, Causes, and Consequences of Stigma: Background for a Model of Migration-Generated Stigma in another window
• 5: Migration, Stigma, and Lived Experiences: A Conceptual Framework for Centering Lived Experiences By San Juanita García , San Juanita García Search for other works by this author on: This Site Google Scholar Tomás R. Jiménez , Tomás R. Jiménez Search for other works by this author on: This Site Google Scholar Seth M. Holmes , Seth M. Holmes Search for other works by this author on: This Site Google Scholar Irena Kogan , Irena Kogan Search for other works by this author on: This Site Google Scholar Anders Vassenden , Anders Vassenden Search for other works by this author on: This Site Google Scholar Lawrence H. Yang , Lawrence H. Yang Search for other works by this author on: This Site Google Scholar Min Zhou Min Zhou Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0008 Open the PDF Link PDF for 5: Migration, Stigma, and Lived Experiences: A Conceptual Framework for Centering Lived Experiences in another window
• 6: Defying Discrimination? Germany’s Ethnic Minorities within Education and Training Systems By Irena Kogan , Irena Kogan Search for other works by this author on: This Site Google Scholar Markus Weißmann , Markus Weißmann Search for other works by this author on: This Site Google Scholar Jörg Dollmann Jörg Dollmann Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0009 Open the PDF Link PDF for 6: Defying Discrimination? Germany’s Ethnic Minorities within Education and Training Systems in another window
• 7: The Lived Experience of Stigma among Immigrant Youth By Heide Castañeda , Heide Castañeda Search for other works by this author on: This Site Google Scholar Seth M. Holmes Seth M. Holmes Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0010 Open the PDF Link PDF for 7: The Lived Experience of Stigma among Immigrant Youth in another window
• 8: How Policies That Impact Migrants Amplify or Mitigate Stigma Processes By Supriya Misra , Supriya Misra Search for other works by this author on: This Site Google Scholar Christian Albrekt Larsen , Christian Albrekt Larsen Search for other works by this author on: This Site Google Scholar Mark L. Hatzenbuehler , Mark L. Hatzenbuehler Search for other works by this author on: This Site Google Scholar Marc Helbling , Marc Helbling Search for other works by this author on: This Site Google Scholar Mikael Hjerm , Mikael Hjerm Search for other works by this author on: This Site Google Scholar Nicolas Rüsch , Nicolas Rüsch Search for other works by this author on: This Site Google Scholar Patrick Simon Patrick Simon Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0011 Open the PDF Link PDF for 8: How Policies That Impact Migrants Amplify or Mitigate Stigma Processes in another window
• 9: Structural Stigma and Health: How U.S. Policies Mitigate and Amplify Stigma By Mark L. Hatzenbuehler Mark L. Hatzenbuehler Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0012 Open the PDF Link PDF for 9: Structural Stigma and Health: How U.S. Policies Mitigate and Amplify Stigma in another window
• 10: Processes and Pathways of Stigmatization and Destigmatization over Time By Paolo Velásquez , Paolo Velásquez Search for other works by this author on: This Site Google Scholar Maureen A. Eger , Maureen A. Eger Search for other works by this author on: This Site Google Scholar Heide Castañeda , Heide Castañeda Search for other works by this author on: This Site Google Scholar Christian S. Czymara , Christian S. Czymara Search for other works by this author on: This Site Google Scholar Elisabeth Ivarsflaten , Elisabeth Ivarsflaten Search for other works by this author on: This Site Google Scholar Rahsaan Maxwell , Rahsaan Maxwell Search for other works by this author on: This Site Google Scholar Dina Okamoto , Dina Okamoto Search for other works by this author on: This Site Google Scholar Rima Wilkes Rima Wilkes Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0013 Open the PDF Link PDF for 10: Processes and Pathways of Stigmatization and Destigmatization over Time in another window
• 11: Immigrants and Processes of Destigmatization By Dina Okamoto , Dina Okamoto Search for other works by this author on: This Site Google Scholar Muna Adem Muna Adem Search for other works by this author on: This Site Google Scholar Doi: https://doi.org/10.7551/mitpress/15529.003.0014 Open the PDF Link PDF for 11: Immigrants and Processes of Destigmatization in another window
• Bibliography Doi: https://doi.org/10.7551/mitpress/15529.003.0015 Open the PDF Link PDF for Bibliography in another window
• Subject Index Doi: https://doi.org/10.7551/mitpress/15529.003.0016 Open the PDF Link PDF for Subject Index in another window
• Strüngmann Forum Report Series Doi: https://doi.org/10.7551/mitpress/15529.003.0017 Open the PDF Link PDF for Strüngmann Forum Report Series in another window
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Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change (2016)

Chapter: 6 conclusions and recommendations, 6 conclusions and recommendations, lessons learned, experiences of other countries.

The experiences of Australia, Canada, and England (see Chapter 4 ) strongly indicate that changing negative social norms that stigmatize people with mental and substance use disorders will require a coordinated and sustained effort. Behavioral health-related norms and beliefs are created and reinforced at multiple levels, including day-to-day contact with people affected by mental and substance use disorders, organizational policies and practices, community norms and beliefs, the media, and governmental law and policy. Successful national-scale anti-stigma programs in other countries shared the following characteristics:

• They were supported by government at the national level.
• Support was committed on a long-term basis, often over decades.
• There was ongoing evaluation and monitoring from the planning phase forward.
• The initiative was multipronged to address the full range of relevant needs.
• Programs and services were coordinated across states (provinces) and across economic and social sectors to reduce fragmentation of efforts.
• Information was collected and disseminated about what worked, with whom, and under which conditions in order to inform the ongoing program development as well as future programs.

The Ryan White Act

In the United States, the Ryan White Care Act (RWCA) provides an example of a coordinated and sustained effort to meet the full spectrum of needs in people with HIV/AIDS. The act was initially passed by Congress in 1990 and has since been reauthorized four times in 1996, 2000, 2006, and 2009. The act supports programs and services at the community, municipal, and state level across the nation. Over the past 25 years, the Ryan White Program has become a critical component of the HIV/AIDS health care system in the United States, serving more than one-half million people ( Crowley and Kates, 2013 ). The history, evolution, and outcomes of the program provide relevant information for future behavioral health anti-stigma initiatives.

The Ryan White Program has evolved to embrace a focus on treatment as prevention, which is consistent with the goals of the Affordable Care Act and the U.S. National HIV/AIDS Strategy. Ongoing evaluation and outcomes research provide future direction for the program, most recently in the areas of health workforce development, insurance coverage, and efforts to scale up programs to achieve population-level impacts ( Crowley and Garner, 2015 ).

The Ryan White Program funds social support-related services in addition to traditional health care and prescription drug programs, including transportation and housing assistance, nutrition services, day care, and dental care ( Taylor, 2010 ). Such “wrap-around” services are provided within the context of an integrated model of care to improve quality of life for people living with HIV/AIDS who face many of the stigma-related barriers as individuals with mental and substance use disorders ( Garfield, 2011 ). Funding is awarded through statutorily established formula grants and through competitive mechanisms with the bulk of funds distributed noncompetitively in response to evolving needs.

One critique of RWCA is that the act did not establish minimum standards for care and services delivery across all states. For example, the act funded AIDS Drug Assistance Programs that were managed by individual states with the states deciding how to allocate funding and set eligibility for enrollment. At the program’s peak height in September 2011, more than 9,000 people with HIV were on state medication waiting lists. Although state and local autonomy regarding implementation and delivery is essential, lessons learned from the AIDS Drug Assistance Programs underscore the need for unifying program standards and illustrate the

important role of the federal government in a national strategy to reduce stigma related to mental and substance use disorders.

An Ecological Framework

Research on stigma toward mental and substance use disorders is challenging and complex in part because it necessarily involves a wide range of independent service systems, numerous sectors and professions, competing agendas, nuanced ethical and cultural issues, and multiple levels of outcome analysis ranging from the individual level to national statistics. Coordinating research across these many layers and systems will require a strategic and harmonious effort on the part of the federal government, private foundations, and academic and health care institutions, and other stakeholders. A coordinated research effort should be finely tuned to the societal and cultural contexts that intentionally or unintentionally endorse or facilitate stigma at various levels, especially the structural level. One assumption of an ecological perspective is that society’s tolerance for or endorsement of a negative norm sets a precedent for stigma at the individual, family, and community levels ( Institute of Medicine and National Research Council, 2014 ). This underscores the need to focus more attention on eliminating structural stigma (see Recommendation 2 ).

Understanding the processes by which factors at the individual, family, community, and social levels interact to produce and maintain stigma will require multidisciplinary, multimethod, and multisector approaches. Research will need to leverage and build on the existing knowledge base related to mental and substance use disorders, stigma change, and other relevant and related fields. Finally, effective research needs to consider the cultural processes, social stratification, ecological variations, and immigrant/acculturation status that are pertinent to understanding the causes and consequences mental and substance disorder stigma ( Institute of Medicine and National Research Council, 2014 . These sociocultural factors are critical elements to consider in developing and testing intervention strategies and in adapting evidence-based practices to unique populations and target audiences to ensure cultural relevance, reach, efficacy, and adoption ( Barrera et al., 2013 ).

CONCLUSIONS AND RECOMMENDATIONS

A national-level approach.

CONCLUSION: The experiences of the U.S. campaigns related to HIV/AIDS and of anti-stigma campaigns in Australia, Canada, and

England demonstrate the need for a coordinated and sustained effort over 2 or more decades to reduce the stigma associated with mental and substance use disorders.

Norms and beliefs related to behavioral health, such as the stigma associated with mental and substance use disorders, are created and reinforced at multiple levels, including day-to-day contact with affected individuals, organizational policies and practices, community norms and beliefs, the media, and governmental law and policy. A number of private and public organizations are already engaged in anti-stigma and mental health promotion efforts, but because these efforts are largely uncoordinated and poorly evaluated, they cannot provide an evidence base for future national efforts.

RECOMMENDATION 1: The U.S. Department of Health and Human Services should take the lead responsibility among federal partners and key stakeholders in the design, implementation, and evaluation of a multipronged, evidence-based national strategy to reduce stigma and to support people with mental and substance use disorders.

Relevant stakeholder groups would include the following:

• consumers in treatment for mental and substance use disorders and consumer organizations;
• families and others whose lives are touched by mental illness or substance use disorders, including suicide-attempt survivors and loss survivors;
• relevant private sector leadership, including major employers;
• relevant foundations and nongovernmental organizations;
• advocates and advocacy groups, including civil rights and disability law experts;
• insurance companies and pharmaceutical manufacturers;
• journalists and others in the news media, including public health media experts;
• health and behavioral health care providers, and administrators, including protective services and social services providers;
• health professional education institutions and professional associations;
• academic researchers, including suicide prevention experts and researchers;
• law enforcement officials and first responders; and
• representatives of federal, state, and local governments.

Early tasks would include the following:

• Identify a lead organization to serve as convener of stakeholders.
• Promote coordination and engagement across local, state, federal, and nongovernmental groups, including the U.S. Departments of Defense, Health and Human Services, Justice, and Labor, and relevant stakeholder groups to pool resources and promote evidence-based approaches.
• Evaluate current laws and regulations related to persons with mental and substance use disorders to identify opportunities to promote changes to support people on the path to recovery.
• Support the development of a strategic plan for research and dissemination of evidence about effective strategies to change social norms related to mental and substance use disorders (see Recommendation 3 ).
• With the federal agencies and other partners, develop a process of identifying and engaging grassroots efforts in each state to promote the implementation of evidence-based programs and fidelity monitoring of service delivery.
• With the federal agencies, establish a long-term, national monitoring system for stigma and stigma reduction.

Collaboration and Coordination

In 2013, eight federal agencies were identified as having programs to support individuals with mental and substance use disorders—the U.S. Departments of Defense, Education, Health and Human Services, Housing, Justice, Labor, Veterans Affairs, and the Social Security Administration—although their specific mission goals vary. To improve the effectiveness and extend the reach of the federal agencies’ programs, there are some ongoing efforts to coordinate across the agencies and their programs ( U.S. Government Accountability Office, 2014 ).

To maximize desired outcomes, collaborative efforts should eschew “ownership” of programs and include cobranding and resource sharing. The Substance Abuse and Mental Health Services Administration (SAMHSA’s) ongoing engagement with stakeholders can support the search for common ground, mutually articulated goals, and shared agendas.

The committee has identified structural stigma and stereotypes of dangerousness and unpredictability as major sources of public and self-stigma. Given the importance of reducing stigma in these areas, early efforts could focus on development of a communications campaign that

targeted policy and decision makers to challenge specific laws, policies and regulations that discriminate against people with mental and substance use disorders. Such a campaign could develop evidence-based public service announcements to hold in readiness for tragic events, such as mass violence, suicide by school and college students, and suicide clusters.

CONCLUSION: Changing stigma in a lasting way will require coordinated efforts, based on the best possible evidence, which are supported at the national level and planned and implemented by a representative coalition of stakeholders. Engaging a wide range of stakeholders would facilitate consensus building and provide the support needed to overcome major obstacles to the implementation of effective anti-stigma programs in the United States. Barriers and challenges include, but are not limited to, conflict among major stakeholder groups regarding best practices and priorities, resource constraints, and the need to target multiple audiences with variable perceptions and priorities, as well as shifting priorities at the national level.

RECOMMENDATION 2: The U.S. Department of Health and Human Services should evaluate its own service programs and collaborate with other stakeholders, particularly the criminal justice system and government and state agencies, for the purpose of identifying and eliminating policies, practices, and procedures that directly or indirectly discriminate against people with mental and substance use disorders.

Strategic Planning for Research

The committee defines strategic planning as the process undertaken by an agency or organization to define its future and formulate a detailed plan to guide its path from the current state to its vision for the future.

CONCLUSION: A planning process usually results in the development of a key document that includes a plan to ensure that communication is maintained across all stakeholders. This element is especially relevant for the Substance Abuse and Mental Health Services Administration given the agency’s ongoing engagement with stakeholders and collaborators. A strategic plan can also serve as the basis of comparison for an ongoing plan for iterative effectiveness monitoring.

RECOMMENDATION 3: The Substance Abuse and Mental Health Services Administration should conduct formative and evaluative research as part of a strategically planned effort to reduce stigma.

SAMHSA’s ongoing program of research on social norms and communications practices could coordinate with national efforts to achieve common goals and objectives. SAMHSA’s Office of Communication’s future activities could also be informed and supported by partners and participating stakeholders.

Because change occurs slowly, outcome evaluations need to be multifaceted and sustained to capture both direct and indirect effects, as well as intended and unintended consequences. An evaluation plan should include and support community-based participatory research that is based on the principle of partnership, in which community partners act as co-learners with academic partners rather than helpers and recipients. This approach involves community stakeholders in helping to define both the change targets and the intervention strategies, as well as in the conduct of the research itself. To inform a national campaign, more in-depth formative and evaluative research is critically needed in three areas: communication strategies, contact-based programs, and the role of peers.

Communication Strategies

Communication science provides a basis for understanding the effects of message features, contents, and platforms on four outcomes: cognitive (e.g., attention and memory), affective (e.g., liking, empathy, and fear), persuasive (e.g., attitude and behavior change), and behavioral (e.g., intents and actions). These effects are not discrete. They depend on characteristics of the target audience or audiences, the media platform, the message source, and the specific content and production features used in the message. For example, in a campaign to counter the stereotype of dangerousness in the wake of a tragic event, relevant audiences would include the media, school officials and teachers, young people, parents, and clergy. Messages would target specific smaller groups and would be designed and delivered with input and support of engaged stakeholders, for example, in donated airtime or volunteered time of high-profile supporters and speakers.

CONCLUSION: Best practices in choosing effective messages first require that a communications campaign develop well-defined goals for each specific group targeted. Effective messages can then be tailored to the specific target audience for the defined goals.

Because of the complexity of designing communication messages, efforts to implement the committee’s recommendation on this topic should be informed by the results of formative and evaluative research. Research is necessary both before message concepts are generated and after message concepts are created for testing in the field. The perspectives of people with lived experience of mental and substance use disorders should inform anti-stigma campaigns at every stage, including design, delivery, and evaluation.

RECOMMENDATION 4: To design stigma-reduction messaging and communication programs, the Substance Abuse and Mental Health Services Administration should investigate and use evidence from formative and evaluative research on effective communication across multiple platforms.

Several general features of effective communication programs have been identified by research and can inform the work in the committee’s recommendations to SAMHSA:

• Identify specific target groups and specific goals appropriate to each group (e.g., legislators and policy makers, employers and landlords, educators, health care practitioners, and people with mental and substance use disorders).
• Make strong appeals that are relevant and personally consequential to particular audiences, for example, young people or veterans.
• Understand how a particular audience orients to a message and what kinds of cues and styles hold their attention so that the message is absorbed and remembered.
• Know what matters most to a specific target group.

Contact-Based Programs

Mixed-methods research has led to the identification of key elements of successful contact-based programs ( Corrigan et al., 2013 , 2014 ). Outcome research on contact demonstrates robust effects in pre-post studies ( Corrigan et al., 2012 ; Griffiths et al., 2014 ) and at follow-up ( Corrigan et al., 2015a ). Although the efficacy of contact-based programs is greater than that of education programs alone in adults across a range of specific target audiences, such as health professionals, college students, and police, evidence shows that one-time contact is not as effective as repeated contact. Education programs are effective in changing stigmatizing attitudes among adolescents.

CONCLUSION: To expand the reach of contact-based programs, efforts will be needed to develop a nationally representative cohort of individuals who have disclosed information about their experiences of mental or substance use disorders. Involvement of those individuals needs to be preceded by the design of programs to aid personal consideration and action on disclosure decisions and of peer training programs to help people consider the risks and benefits of disclosure.

RECOMMENDATION 5: To decrease public and self-stigma and promote affirming and inclusive attitudes and behaviors targeted to specific groups, the Substance Abuse and Mental Health Services Administration should work with federal partners to design, evaluate, and disseminate effective, evidence-based, contact-based programming.

The Role of Peers

Peers play an essential role in combatting stigma, in part because they model personal recovery. Their role is critical in helping individuals to overcome the debilitating forces of self-stigma. Peer support programs and services include social and emotional support, as well as practical support related to quality-of-life decisions, delivered by people with mental and substance use disorders. Peer support has existed since the 1970s, but in 2001 several states began efforts to certify and train the peer specialist workforce. By 2012, 36 states had established such programs, although there is considerable variation in the certification programs across these states ( Ostrow and Adams, 2012 ). State programs vary in terms of stage of development and certification requirements, including the content and process of training, examination criteria, and requirements for continuing education and recertification ( Kaufman et al., 2012 ).

Most research on the outcomes of peer services has focused on quality-of-life measures. Few data are available about the costs and benefits of these programs, although the research suggests that people who use peer support services are more likely to use other behavioral health services of all kinds, including professional services and prescription drugs, which may lead to improved outcomes ( Landers and Zhou, 2014 ). Although more peers are becoming certified, stakeholders disagree about the risks and benefits of professionalizing the role given grassroots origins of peer support in the consumer movement ( Ostrow and Adams, 2012 ).

CONCLUSION: In the United States, there is no established and accepted set of national or state competencies or standards for peer

specialists, such as those that apply to other health professionals at state levels.

Although stakeholders do not agree on the risks and benefits of certification for peer support providers, it may contribute to the quality and outcomes of peer services and facilitate research on the effectiveness of these services across a range of outcomes. Programs need to be appropriately targeted to the audience or audiences and implemented at the relevant geographic level. Components of this effort would include standardization of preparation for peer service providers and development of practice guidelines for referral to and delivery of peer services across agencies and organizations engaged in this work. SAMHSA has taken steps in this direction with its 2009 Consumer-Operated Service Evidence-Based Practices Toolkit ( Chapter 4 ) and continues to have an important role to play in the development and dissemination of these products and programs across the nation. The National Federation of Families for Children’s Mental Health offers a national certification for parent support providers that could serve as a model for future efforts to expand the reach of high-quality peer support services.

RECOMMENDATION 6: The Substance Abuse and Mental Health Services Administration should work with partners to design, support, and assess the effectiveness of evidence-based peer programs to support people with mental and substance use disorders along the path to recovery and to encourage their participation in treatment.

Development of a national strategy for eliminating the stigma of mental and substance use disorders is a challenging, long-term goal that will require collaboration across federal agencies, support from governments at all levels, and engagement of a broad range of stakeholders. No single agency can implement an effective national strategy, but SAMHSA brings specific and unique strengths including well-established stakeholder relations, commitment to the recovery model, and a history of promotion and implementation of prevention and early intervention strategies. Early objectives will include consensus building across a range of issues, design of cost-sharing arrangements, and development and implementation of a research strategy, including a system for monitoring change public attitudes, and mechanisms for disseminating information to inform future anti-stigma interventions.

Estimates indicate that as many as 1 in 4 Americans will experience a mental health problem or will misuse alcohol or drugs in their lifetimes. These disorders are among the most highly stigmatized health conditions in the United States, and they remain barriers to full participation in society in areas as basic as education, housing, and employment. Improving the lives of people with mental health and substance abuse disorders has been a priority in the United States for more than 50 years. The Community Mental Health Act of 1963 is considered a major turning point in America's efforts to improve behavioral healthcare. It ushered in an era of optimism and hope and laid the groundwork for the consumer movement and new models of recovery. The consumer movement gave voice to people with mental and substance use disorders and brought their perspectives and experience into national discussions about mental health.

However over the same 50-year period, positive change in American public attitudes and beliefs about mental and substance use disorders has lagged behind these advances. Stigma is a complex social phenomenon based on a relationship between an attribute and a stereotype that assigns undesirable labels, qualities, and behaviors to a person with that attribute. Labeled individuals are then socially devalued, which leads to inequality and discrimination. This report contributes to national efforts to understand and change attitudes, beliefs and behaviors that can lead to stigma and discrimination. Changing stigma in a lasting way will require coordinated efforts, which are based on the best possible evidence, supported at the national level with multiyear funding, and planned and implemented by an effective coalition of representative stakeholders.

Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change explores stigma and discrimination faced by individuals with mental or substance use disorders and recommends effective strategies for reducing stigma and encouraging people to seek treatment and other supportive services. It offers a set of conclusions and recommendations about successful stigma change strategies and the research needed to inform and evaluate these efforts in the United States.

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PSYCH 424 blog

Social inequality from discrimination     .

Social Inequality from Discrimination

Alessandra DeVito

Stereotyping, prejudice, and discrimination are a trifecta that perpetuates social inequality and injustice, yet their distinctions are often blurred. Understanding each component is pivotal in dismantling systemic biases and fostering a more inclusive society.

Stereotyping, involves making assumptions about individuals based on characteristics such as race, gender, or religion. These oversimplified beliefs create a rigid framework through which people are perceived, often ignoring their individuality. Whether it’s assuming “all Asians are good at math” or “all women are nurturing”, or “Nearly half of Americans (46%) say there is “a lot” of discrimination against Black people”.  Stereotypes diminish the complexity of human experience and reinforce harmful biases.

Prejudice, takes stereotypical beliefs a step further by attaching emotions such as dislike or hostility to certain groups. It’s the emotional response to perceived differences, often stemming from fear, ignorance, or social conditioning. Prejudice not only clouds judgment but also influences behavior, fueling discrimination and creating barriers to social cohesion.

Discrimination, is the action or behavior resulting from prejudice. It’s the manifestation of biased attitudes in real-world interactions, leading to unequal treatment or opportunities for certain individuals or groups. Discrimination can take various forms, from overt acts like racial profiling to subtler forms such as microaggressions in everyday interactions. Regardless of its guise, discrimination reinforces power imbalances and perpetuates systemic inequalities.

Overall, understanding the interconnected nature of stereotyping, prejudice, and discrimination is crucial in combating social injustices. By challenging stereotypes, addressing prejudice, and actively working to eliminate discriminatory practices, we can strive towards a more equitable and inclusive society where individuals are valued for their unique qualities rather than judged based on preconceived notions. It’s only through collective awareness and action that we can dismantle the barriers that divide us and pave the way for a more just and compassionate world.

https://www.pewresearch.org/short-reads/2021/03/18/

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Psychology, D., & Nelson, A. (2024, March). https://psu.instructure.com/courses/2313584/modules/items/40248716 . Login.microsoftonline.com; Penn State. https://psu.instructure.com/courses/2313584/modules/items/40248716canvas lecture materials

Great post, I too wrote about discrimination and I love that we went two separate ways with it. I could not agree more regarding the eradication of these ridiculous notions and a collective understanding of why they exist and what they mean is imperative for healing. I was curious, did those statements come from the Pew research? It’s so bizarre how people just make blanket statements based on uneducated and baseless information likely passed on from another and not a reliable source of information. Well done. It was cool to see a different perspective on the same topic.

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Prejudice, Stigma, Privilege, and Oppression pp 1–14 Cite as

An Introduction to Prejudice, Stigma, Privilege, Oppression, Discrimination, and Clinical Science

• Lorraine T. Benuto 5 ,
• Melanie P. Duckworth 5 ,
• Akihiko Masuda 6 &
• William O’Donohue 5  
• First Online: 12 May 2020

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Clinical psychology as a profession could be justifiably accused of neglecting or at best only obliquely addressing prejudice, stigma, privilege, oppression, and discrimination. Admittedly, it is not clear that any behavioral health profession or health profession for that matter has done any better. While there is no doubt that these problems have existed for centuries and currently exist in manifold ways, the profession of clinical psychology has been relatively indirect at dealing with these. For example, clinical psychologists, with the possible exception of feminist therapists, have not developed standardized and valid measures of the extent to which their clients’ presenting problems may be due to prejudice and discrimination. However, unfortunately, feminist therapies have also not been sufficiently studied through randomly controlled trials to determine their efficacy and safety (see Chambliss). Clinical psychologists have not developed interventions that directly ameliorate the effects of these problems on our clients. This book provides an overview of potential ways to mitigate this issue.

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Benuto, L.T., Duckworth, M.P., Masuda, A., O’Donohue, W. (2020). An Introduction to Prejudice, Stigma, Privilege, Oppression, Discrimination, and Clinical Science. In: Benuto, L., Duckworth, M., Masuda, A., O'Donohue, W. (eds) Prejudice, Stigma, Privilege, and Oppression. Springer, Cham. https://doi.org/10.1007/978-3-030-35517-3_1

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Understanding and Addressing Mental Health Stigma Across Cultures for Improving Psychiatric Care: A Narrative Review

Ahmed a ahad.

1 Psychiatry and Behavioral Sciences, Florida International University, Herbert Wertheim College of Medicine, Miami, USA

Marcos Sanchez-Gonzalez

2 Health Services Administration, Lake Erie College of Osteopathic Medicine, Bradenton, USA

Patricia Junquera

Stigma, characterized by negative stereotypes, prejudice, and discrimination, is a significant impediment in psychiatric care, deterring the timely provision of this care and hindering optimal health outcomes. Pervasive in all aspects of psychiatric care, stigma leads to delayed treatment, increased morbidity, and diminished quality of life for those with poor mental health. Hence, better understanding the impact of stigma across different cultural contexts is critically essential, aiming to inform culturally nuanced strategies to minimize its consequences and contribute to a more equitable and effective psychiatric care system. The purpose of the present literature review is twofold (i) to examine the existing research on the stigma surrounding psychiatry across different cultural contexts and (ii) to identify the commonalities and differences in the nature, magnitude, and consequences of this stigma in different cultures in the psychiatry field. In addition, potential strategies for addressing stigma will be proposed. The review covers a range of countries and cultural settings, emphasizing the importance of understanding cultural nuances to combat stigma and promote mental health awareness globally.

Introduction and background

Stigma, characterized by societal prejudice and discrimination, profoundly influences psychiatric care, creating barriers to the timely recognition and treatment of mental health disorders [ 1 ]. Deeply embedded in societal norms, stigma is a multifaceted issue permeating every level of psychiatric care, leading to delayed treatment, increased morbidity, and a diminished quality of life for patients.

The importance of addressing stigma in psychiatry cannot be overstated as stigma impacts individuals seeking care, their families, healthcare professionals, and broader society. At the individual level, stigma can lead to fear and avoidance of mental health services, causing delays in seeking help even when a patient is in dire need. Delays in seeking care can exacerbate mental health conditions leading to worse outcomes and reduced quality of life [ 2 ]. For families, the stigma can lead to shame and isolation, making seeking necessary support and resources more difficult. Interestingly, in healthcare professionals, stigma can lead to burnout and demoralization, reducing the quality and provision of care. Stigmatization can also create barriers between healthcare providers and patients, complicating matters to establishing trustful and therapeutic relationships, which are essential for effective care [ 1 ]. For society at large, stigma can result in the misallocation of resources, with mental health services often being underfunded and overlooked [ 3 ]. Hence stigma has profound effects at personal and societal levels, negatively impacting multiple levels of the psychotic care continuum. 

Addressing the stigma surrounding mental health can significantly enhance the effectiveness of psychiatric care. To this end, developing programs and strategies that foster a culture of understanding and acceptance may encourage more individuals to seek help when they need it, improving early detection and intervention, which are crucial for better health outcomes. Furthermore, challenging and changing stigmatizing attitudes can improve the therapeutic relationship between healthcare providers and patients, leading to more personalized and effective treatment strategies.

Stigma, however, is not a monolithic entity but varies across cultures, influenced by distinct societal norms, values, and beliefs. Understanding these cultural variations is essential for developing effective, culturally sensitive interventions. Therefore, this literature review aims to examine the manifestation and impacts of stigma across different cultural contexts, laying the foundation for tailored strategies to combat this healthcare barrier.

Stigma as a psychological construct

In the literature, there have been several attempts at creating instruments to measure and understand stigma as a psychological construct in the context of mental health. In this vein, the Internalized Stigma of Mental Illness (ISMI) scale and the Perceived Devaluation-Discrimination Scale, among others, seek to quantify stigma more objectively [ 4 , 5 ] . The ISMI scale, as defined by Ritsher et al. (2003), measures the subjective experience of stigma, including the internalization of negative stereotypes and beliefs about mental illness [ 4 ]. It includes five subscales: Alienation, Stereotype Endorsement, Discrimination Experience, Social Withdrawal, and Stigma Resistance. These subscales were further defined as follows: (i) Alienation: The feeling of being less than a full member of society due to one's mental illness, (ii) Stereotype Endorsement: The extent to which the individual agrees with common negative stereotypes about people with mental illness, (iii) Discrimination Experience: Personal experiences of rejection or exclusion due to mental illness, (iv) Social Withdrawal: The extent to which the individual avoids social situations for fear of being stigmatized, and (v) Stigma Resistance: The individual's ability to resist or counteract stigma. The Perceived Devaluation-Discrimination Scale, as described by Link (1987), measures the extent to which individuals believe that most people will devalue or discriminate against someone with a mental illness [ 5 ]. It focuses on the individual's perceptions of societal attitudes, rather than their personal experiences with stigma. Overall, while the ISMI scale can give insights into the internalization and personal experience of stigma, the Perceived Devaluation-Discrimination Scale can provide a view of societal attitudes and perceived discrimination. The above are crucial to understanding the full landscape of stigma in psychiatry across different cultures by helping identify where interventions might be most needed and most effective, whether at the level of societal attitudes, personal beliefs, or both. The pervasive nature of stigma presents a daunting challenge to psychiatry, necessitating a rigorous and nuanced approach to its understanding and mitigation. However, despite recent awareness campaigns, the field still struggles with the barriers that stigma imposes on patient care, necessitating additional analysis of the effects.

Individual and societal impact of stigma

Stigmatization of mental illness across cultures is a significant barrier to psychiatric care. The stigma can lead to delayed diagnosis and treatment-seeking behaviors, reduced quality of life, and an increased risk of social exclusion and discrimination [ 2 ]. Furthermore, mental illness stigma often intersects with other forms of stigma, such as gender, race, and socio-economic status, leading to further marginalization of already vulnerable populations making it challenging to provide equitable, culturally sensitive, and effective psychiatric care to individuals with mental illness. Accumulating research suggests that stigma toward mental illness is common in various cultures, which can affect mental illness diagnosis, treatment, and management [ 6 ]. Furthermore, some studies reveal that mental health stigma manifests differently across cultures and can be influenced by cultural beliefs, attitudes, and values [ 7 ]. The stigma surrounding psychiatry and mental health disorders has numerous detrimental effects on individuals and communities, including:

1. Delayed Treatment-Seeking Behavior

Stigma plays a significant role in delaying treatment-seeking behavior for individuals struggling with mental health issues. The fear of being labeled, ostracized, or misunderstood due to their condition often deters individuals from seeking help promptly. According to a study by Clement et al. (2015), stigma was associated with an increased likelihood of delaying or avoiding seeking help for mental health concerns [ 8 ]. Consequently, symptoms may worsen over time, escalating the condition's severity and making treatment and prospective recovery more challenging. Healthcare delays can also lead to decreased self-esteem and increased depressive symptoms, creating a vicious cycle of self-blame, isolation, and hopelessness. Prolonged untreated mental health issues can further impair an individual's functionality in various life domains, including work, relationships, and self-care, thus reducing their overall quality of life [ 9 ].

2. Social Isolation and Discrimination

Stigma can lead to social isolation and discrimination for those affected by mental health issues. Brohan and Thornicroft (2010) found that individuals with mental health disorders often face discrimination in multiple life domains, including employment and interpersonal relationships [ 2 ]. The negative stereotypes and misconceptions surrounding mental illness often result in a lack of understanding and empathy from others, leading to social exclusion [ 10 ]. Individuals with mental health issues might face discrimination in various aspects of life, including the workplace, where they might encounter bias in hiring, job retention, and career advancement. Furthermore, to complicate matters, discrimination can further strain personal relationships, as friends and family may distance themselves due to discomfort, fear, or misunderstanding, exacerbating feelings of isolation and loneliness [ 9 ].

3. Reduced Treatment Adherence

Stigma can significantly impact adherence to mental health treatments. Sirey et al. (2001) found that perceived stigma predicted treatment discontinuation in older adults with depression [ 11 ]. People living with mental health conditions may avoid or discontinue treatment due to fear of being identified as a mental health patient. This fear could stem from concerns about the stigma associated with visiting mental health facilities, taking psychiatric medications, or being seen engaging in therapeutic activities [ 12 ]. Non-adherence to treatment regimens can lead to suboptimal treatment outcomes, hinder recovery, and increase the risk of relapse or worsening symptoms. Furthermore, stigma can diminish self-efficacy, making individuals less likely to actively engage in their treatment process, which is crucial for successful recovery.

4. Perpetuation of Misconceptions

Stigmatizing attitudes towards mental illness contribute to the perpetuation of harmful stereotypes and misinformation. AsCorrigan and Watson (2007) discussed, stereotypes such as appearing dangerous, unpredictable, or culpable for their illness can make people with mental illness perceived inaccurately as dangerous or to blame for their condition, both internally and externally [ 12 ]. Stereotyping, deeply embedded in societal attitudes, can foster a culture of fear, rejection, and discrimination against individuals with mental health conditions. Misconceptions often result in people with mental health issues being perceived inaccurately as dangerous, unpredictable, or responsible for their condition. In addition, misinformation can hinder public understanding and acceptance of mental illness, exacerbating stigma while negatively influencing policy and legislation, leading to inadequate funding and support for mental health services.

5. Influence of Gender on Stigma

The impact of stigma on individuals with mental illness is known to vary across different social and demographic categories, including gender. Research evidence indicates that the experience of stigma related to mental illness can be significantly different for men and women, and these differences can be further influenced by cultural context.

In some societies, women seem to face higher levels of stigma related to mental health issues compared with men. A study by Al Krenawi et al. (2006) conducted in the Bedouin-Arab community found that women experienced a significantly higher degree of stigma associated with mental illness than their male counterparts [ 13 ]. This may be due to traditional gender roles and societal expectations, which often place women in a more subordinate position and associate mental illness with weakness or vulnerability. Women with mental illnesses may therefore face dual discrimination - first for their gender and then for their mental health condition. This can make women less likely to seek help for mental health issues, further exacerbating their condition and creating a vicious cycle of stigma and untreated mental illness.

However, the influence of gender on stigma is not uniform across all cultures. Ayalon and Areán's (2004) study on older adults in an Arab cultural context found that men reported higher levels of perceived stigma related to mental illness than women [ 14 ]. This discrepancy might be rooted in traditional masculine norms prevalent in many Arab societies, which value strength, stoicism, and emotional control. Mental illness, which is often erroneously perceived as a sign of emotional weakness or lack of control, can be particularly stigmatizing for men in these contexts. Furthermore, the expectation for men to be the primary earners and providers in the family can make the potential economic impacts of mental illness, such as unemployment or reduced productivity, particularly stigmatizing.

These findings underscore the importance of considering gender and cultural context in understanding and addressing stigma related to mental illness. It is crucial to develop and implement culturally sensitive strategies that consider these differences in the experience of stigma. This might involve, for example, promoting mental health literacy, challenging harmful gender norms, and providing gender-specific mental health services. We can move toward a more equitable and effective mental health care system by acknowledging and addressing the unique stigma-related challenges different groups face.

Ethnic and cultural variations in stigma

The stigma surrounding psychiatry, as research suggests, manifests differently across cultures due to various factors [ 7 ]. This stigma operates at various levels, including individuals, families, healthcare providers, and society, and cultural norms, religious beliefs, and social attitudes influence its manifestations and implications.

At the individual level, mental health issues may be internalized differently depending on cultural background. For instance, some Asian cultures may view mental health issues as a sign of personal weakness or a failure of self-control [ 15 ]. The internalization of stigma can significantly influence an individual's self-perception and willingness to seek help. In the family context, cultural beliefs also play a significant role in shaping attitudes toward mental health. A study by Yang and Kleinman (2008) found that in Chinese culture, mental illness is often attributed to social and interpersonal factors, such as family conflict [ 16 ]. Such attributions can contribute to a sense of shame or blame within the family, exacerbating the stigma experienced by the individual with mental illness.

Healthcare providers are not immune to these cultural beliefs and they can influence their practice. In some cultures, mental illnesses are viewed through a supernatural lens rather than a medical one. Girma et al. (2013) found that in Ethiopian culture, mental illness is commonly associated with supernatural causes, such as evil spirits or curses [ 17 ]. This widely held belief can influence healthcare providers' approach and potentially limit the provision of evidence-based psychiatric care.

Lastly, at the societal level, these cultural perceptions and beliefs can contribute to the broader social stigma surrounding mental health, leading to discrimination and social exclusion. Differences in societal perceptions across cultures can lead to distinct forms of discrimination, further compounding the challenges faced by individuals with mental health issues. Hence, understanding and addressing cultural stigma in psychiatry involves a multifaceted approach that considers individual, family, healthcare providers, and societal levels. Each level offers potential avenues for stigma reduction and improved mental health outcomes.

Asian Cultures

In many Asian societies, mental health issues are often perceived as a sign of personal weakness or a failure of self-control. The concept of 'face' is significantly influential, and the stigma associated with mental illness can be seen as bringing shame to the family [ 15 ]. For instance, a strong cultural emphasis on academic and professional achievement in South Korea contributes to stigmatizing attitudes toward mental illness, which may discourage individuals from seeking help [ 18 ].

African Cultures

Mental illnesses in some African cultures are often attributed to spiritual or supernatural causes such as curses or possession by evil spirits. This understanding can contribute to high levels of stigma and deter individuals from seeking psychiatric help [ 19 ]. In Ethiopia, the belief in supernatural causes of mental illness has been reported, leading to the stigmatization of affected individuals [ 17 ].

Arab Cultures

Mental illness in Arab societies is frequently viewed as a form of divine punishment. Religious belief perpetuating mental health stigma can lead to delayed or avoided treatment as individuals may resort to religious or spiritual interventions [ 20 ].

Latin American Cultures

In some Latin American cultures, mental illness is often attributed to personal weakness or lack of willpower. This perspective could stigmatize individuals with mental health disorders and discourage them from seeking psychiatric care [ 21 ].

Western Cultures

In Western societies, stigma often stems from misconceptions about mental illness, including the belief that individuals with mental health disorders are dangerous or unpredictable. While mental illness is recognized more as a health issue, stigma still exists, often resulting in social exclusion and discrimination [ 12 ].

Additionally, culture-bound syndromes, defined here as a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease within specific cultures or societies, are a critical component of a discussion on cultural stigma in psychiatry. That is to say, culture-bound syndromes refer to unique mental health conditions closely tied to specific cultures or ethnic groups. For instance, among the Latino community, 'Ataque de Nervios,' characterized by uncontrollable shouting, crying, trembling, and sometimes aggressive behavior, is a recognized condition often associated with a stressful event such as a panic attack [ 21 ].

Hence, a clinician's awareness and understanding of such culture-bound syndromes can enhance their diagnostic and therapeutic effectiveness. In fact, a study conducted by Hughes and Wintrob (1995) in New York discovered a significant improvement in therapeutic relationships when clinicians were knowledgeable about culture-bound syndromes prevalent in their patients' cultures, such as 'Qigong Psychotic Reaction' in Chinese immigrants, a condition associated with overdoing Qigong, a type of spiritual martial art [ 22 ].

Furthermore, cultural competence, which includes knowledge about culture-bound syndromes, has a substantial impact on treatment outcomes. Culturally competent care, defined by an understanding and respect for cultural differences, can improve patient satisfaction and adherence to treatment. A systematic review by Truong et al. (2014) demonstrated the positive effect of cultural competence on healthcare outcomes, including in a Native American population suffering from 'Ghost Sickness,' a culture-bound syndrome characterized by feelings of terror, weakness, and a sense of impending doom, often linked to the perceived presence of the supernatural [ 23 ].

Simultaneously, addressing culture-bound syndromes can influence and reduce mental health stigma across cultures. Misinterpretation of these syndromes can contribute to stigma, as individuals might be wrongly diagnosed or misunderstood. For instance, Kirmayer's (2012) study on cultural variations in depression and anxiety found that misunderstanding culture-bound syndromes, such as 'Taijin Kyofusho,' a Japanese syndrome characterized by an intense fear that one's body or bodily functions are displeasing to others, could lead to misdiagnosis and increase stigma [ 24 ]. Practices that raise awareness of culture-bound syndromes offer a deeper, richer perspective on cultural influences on mental health. Awareness and understanding of these syndromes can enhance diagnostic and treatment approaches, optimize patient outcomes, and potentially contribute to reducing mental health stigma across various cultures.

Taken together, these studies highlight the importance of understanding cultural contexts when addressing the stigma surrounding mental health disorders and psychiatric care. The cultural beliefs and attitudes towards mental health disorders, summarized below in Table ​ Table1, 1 , influence how stigma is manifested and the approaches needed to reduce it effectively. By acknowledging cultural variations, more culturally appropriate and effective strategies can be developed to combat stigma and improve mental health care across different societies worldwide.

Strategies for addressing mental health stigma

Several strategies have been proposed in the literature to address the stigma surrounding psychiatry across cultures:

1. Public Awareness Campaigns

Awareness campaigns can be instrumental in dismantling misconceptions and fostering understanding of mental health disorders. Public awareness campaigns can dispel myths, reduce stigma, and encourage empathy towards affected individuals by promoting accurate information about mental illnesses, their prevalence, and the possibilities for recovery. For instance, a study by Pinfold et al., (2003) showed that public campaigns using direct social contact with people with mental illness could significantly improve public attitudes towards mental health [ 25 ]. The study by Pinfold et al., (2003) implemented educational interventions in UK secondary schools, consisting of video presentations and direct social contact with individuals who had personal experiences with mental illness [ 25 ]. The UK campaign's goal was to challenge common myths about mental illness and replace them with accurate information. The results showed that students exposed to this intervention demonstrated less fear and avoidance of people with mental health problems and were more likely to see them as individuals rather than defining them by their illness.

2. Cultural Competency Training for Healthcare Professionals

Medical education can equip healthcare providers with the necessary knowledge and skills to understand and respect their patients' cultural backgrounds and experiences, which is critical for reducing stigma in healthcare settings. Research indicates that healthcare providers who lack cultural competence may inadvertently contribute to stigma, further deterring patients from seeking help [ 26 ]. A study by Kirmayer (2012) found that cultural competence training improved healthcare providers' understanding of cultural influences on health behaviors and led to more effective patient-provider communication, thereby reducing perceived stigma [ 24 ]. For instance, a study in Australia provided cultural competency training to healthcare providers and found that their understanding of Indigenous Australians' health needs significantly improved [ 24 ]. They were able to better respect and incorporate Indigenous perspectives in treatment, which led to increased trust and better patient-provider relationships.

3. Peer Support Programs

People with lived experiences of mental health disorders who share their stories, can normalize mental health issues and challenge stigma. By providing real-life examples of individuals living with and managing their mental health disorders, peer-to-peer advocacy programs may debunk myths and reduce the perceived 'otherness' of mental illness. A study by Pitt et al. (2013) showed that peer support reduced self-stigma and improved self-esteem and empowerment among individuals with mental health disorders [ 27 ]. The study focused on "consumer-providers," individuals who had personally experienced mental health issues and were now providing support services to others. The findings demonstrated that consumer-providers significantly reduced self-stigma among service users, while also improving self-esteem and feelings of empowerment.

4. Community-Based Mental Health Services

Integrating mental health care into primary care and community settings can reduce the stigma associated with seeking psychiatric help. This emphasis on integrating measures for mental well-being along with other routine and standard primary care protocols allows mental health care to be more accessible and less intimidating, encouraging individuals to seek help when needed. A study by Thornicroft et al. (2015) found that community-based mental health services can reduce stigma and discrimination and improve mental health outcomes [ 28 ]. For instance, a program in India called the MANAS project integrated mental health services into primary care and community settings [ 28 ]. This approach not only made mental health services more accessible but also more 'normal' and less stigmatizing. The project reported a significant increase in the utilization of mental health services and a decrease in the experience of stigma among service users.

5. Evidence-Based Approach

Another approach to overcoming the barriers created by stigma is to use evidence-based methods to reduce mental illness stigma. A meta-analysis by Corrigan et al. (2016) found that various evidence-based interventions, including education and contact-based interventions, can effectively reduce mental illness stigma across cultures [ 9 ]. Contact-based interventions involve interaction between people with mental illness and members of the public to challenge negative attitudes and beliefs. Education-based interventions aim to increase knowledge and awareness of mental illness and reduce negative stereotypes. Educational interventions can be delivered in a variety of formats, such as in-person workshops, online courses, and mass media campaigns.

The role of the healthcare provider in ameliorating stigma cannot be overlooked. Moreover, a review by Ayalon and Areán (2004) suggests that mental health providers can play a critical role in reducing mental illness stigma by engaging in culturally sensitive practices [ 14 ]. For instance, mental health providers can develop cultural competence, which refers to the ability to provide effective services to individuals from diverse cultural backgrounds. Cultural competence involves understanding and respecting cultural differences, tailoring treatment to meet diverse populations' unique needs, and integrating cultural factors into treatment planning.

Research also highlights that stigma towards mental illness has significant implications for treating and managing mental health conditions. For example, several studies suggest that stigma can lead to delayed diagnosis and treatment-seeking behaviors [ 13 , 16 ]. This is concerning because early intervention is critical for managing mental illness and improving outcomes for individuals living with these conditions. Considering the documented impact of stigma on timely diagnosis and treatment-seeking behaviors, strategies such as public awareness campaigns, cultural competency training for healthcare professionals, peer support programs, community-based mental health services, and an evidence-based approach can play a crucial role in combating cultural stigma in psychiatry. These measures collectively contribute to improved awareness, understanding, and acceptance of mental health conditions, thus facilitating early intervention and better management of mental illnesses across diverse cultural contexts.

Conclusions

Stigma surrounding mental health and psychiatric care is a complex and multifaceted issue that varies across ethnic and cultural contexts. To effectively address and reduce stigma in mental healthcare settings, developing culturally sensitive interventions and promoting understanding and acceptance of mental health issues is crucial. By doing so, we can work towards improving access to mental health care and promoting the well-being of individuals and communities across the globe.

Overall, the literature suggests that stigma is a complex and pervasive issue that affects individuals with mental illness across cultures. The studies reviewed reveal that mental illness stigma is influenced by cultural beliefs, attitudes, and values, and can manifest in different ways across cultures. It is important to understand these cultural differences to develop more effective interventions to reduce mental illness stigma and improve outcomes for individuals living with mental illness. Furthermore, stigma across cultures impacts psychiatric care in various ways and can create significant barriers to effective treatment. Evidence-based interventions, including education, contact-based interventions, and culturally sensitive practices can help overcome these barriers. Mental health providers should strive to develop cultural competence and deliver culturally sensitive interventions to meet the needs of diverse populations. Research to understand the impact of stigmatization of mental health patients and its impact in providing services is warranted. Reducing mental illness stigma is critical to providing equitable, effective, and compassionate psychiatric care to individuals with mental illness.

The authors have declared that no competing interests exist.