Stigma as a fundamental cause of population health inequalities

Impacts of stigma and discrimination on people with obesity who smoke cigarettes

Stigma is the state of social devaluation due to a trait or group identity; weight and smoking-based self-, felt-, and enacted stigma may have detrimental health effects and pose barriers to smoking cessation. This study examined associations between stigma, discrimination, and health for people with overweight or obesity (body mass index [BMI] ≥ 25) who smoke cigarettes (cigarettes smoked/day ≥ 5) who reported interest in quitting smoking and minimizing weight gain. Participants (N = 63; predominantly women (81.0 %), White (63.5 %) or Black/African American (31.7 %), and heterosexual (85.7 %) with 50 % having a yearly income below $50,000) completed the measures of stigma (i.e., Weight Bias Internalization Scale and Internalized Stigma of Smoking Inventory), discrimination (i.e., Everyday Discrimination Scale), and symptoms of depression, weight, smoking, nicotine dependence, and concerns about gaining weight while quitting smoking were measured. Those who reported more internalization of weight bias and more everyday discrimination reported greater depressive symptomatology and greater concern about gaining weight while quitting smoking, with depressive symptomatology fully mediating both internalization of weight bias and everyday discrimination's relation with concern about gaining weight while quitting smoking. There was also an association of smoking felt-stigma, but not self- or enacted-stigma, with symptoms of depression. Stigma's associations with symptoms of depression and post-cessation weight concern suggest barriers to effective behavior change, and interventions may consider targeting processes for coping with stigma experienced by this population.

Social Determinants of Health, Cardiovascular Health, and Mortality in Sexual Minority Individuals in the United States

BACKGROUND

Despite recent efforts to address health disparities regarding social determinants of health (SDOH), the intersection between SDOH and cardiovascular health (CVH) outcomes in sexual minority (SM) individuals remain largely underexplored.

OBJECTIVES

This study sought to investigate associations between SDOH profile and CVH and mortality outcomes among SM individuals in the United States.

METHODS

All participants aged ≥18 years surveyed in the 2013 to 2017 National Health Interview Survey were included, except those with missing data on SM status, any CVH or SDOH domain, or any other covariate. SM status was self-reported and categorized as lesbian/gay, bisexual, or uncertain. Participants' SDOH profile was quantified using a 6-domain (economic stability, neighborhood/physical environment/social cohesion, community and social context, food, education, and health care system), 38-item score, with higher scores indicating greater social deprivation. CVH was adapted from the American Heart Association's Life's Essential 8 framework. Because detailed dietary data were unavailable, a 7-item (hypertension, diabetes mellitus, hypercholesterolemia, smoking, physical inactivity, inadequate sleep, and obesity) CVH score was used, with higher scores indicating worse CVH. Additionally, cardiovascular mortality was ascertained through the National Death Index using death certificate information.

RESULTS

The study sample consisted of 57,182 participants, representing a population of 82,826,690 persons. A worse composite SDOH score was associated with a worse CVH score in both heterosexual (adjusted rate ratio: 1.14; 95% CI: 1.13-1.15; P < 0.001) and SM individuals (adjusted rate ratio: 1.16; 95% CI: 1.12-1.20; P < 0.001), with associations appearing to be potentially stronger in the latter (Pinteraction = 0.042). Subgroup analysis demonstrated consistent associations among gay/lesbian individuals and bisexual individuals, but not in those with other or uncertain sexual orientations. Further exploratory analysis showed that a worse composite SDOH score was significantly associated with higher risk of cardiovascular mortality in both heterosexual (adjusted HR: 1.17; 95% CI: 1.06-1.28; P = 0.002) and SM individuals (adjusted HR: 2.25; 95% CI: 1.24-4.08; P = 0.008), with associations being significantly stronger in the latter (P interaction = 0.006).

CONCLUSIONS

An unfavorable SDOH profile was associated with worse CVH scores and higher cardiovascular mortality risk among SM individuals in the United States compared to their heterosexual counterparts.

Exploring the drivers of adolescent sexual and reproductive healthcare-seeking behavior in northwestern Botswana: a cross-sectional analysis

BACKGROUND

Research examining young people's healthcare-seeking behaviors in Sub-Saharan Africa has largely focused on university or out-of-school youth who are sexually active and/or HIV-positive. Healthcare-seeking behavior in younger adolescents has been less well studied even though it is during secondary school years that the majority of adolescents become sexually active. There is limited evidence to guide strategies that schools, health facilities, and social service agencies use to encourage adolescents to utilize sexual and reproductive health resources prior to sexual debut.

METHODS

This study used cross-sectional data collected in 2021 during school hours from eleven secondary schools in the Northwest District of Botswana. Adolescents ages 14-19 years completed surveys using hand-held tablets. Descriptive statistics were run for all variables; bivariate analyses examined their association with skipped visits. Logistic regression identified correlates of forgone visits. The outcome variable of interest was whether a respondent had ever forgone a visit to a health clinic for sexual and reproductive health information or services.

RESULTS

553 adolescents, provided information used for analysis. One fifth of respondents had had sexual intercourse (21%). Most had not been tested for HIV (54%), did not know their HIV status (60%), or had not had an STI other than HIV (92%). Teachers (31%) and female family members (31%) were the most frequently consulted sources on bodily changes during adolescence. In the bivariate analysis, age, gender, sexual experience, HIV testing, awareness of HIV status, and having had an STI were significantly associated with forgone visits. At the multivariate level, younger respondents and those who had never been tested for HIV or had an STI had lower odds of forgone visits compared to their older peers and those who had been tested or had an STI. The most common reasons for forgoing visits reflected perceptions that nurses were unfriendly and did not believe adolescents should have sex. Students identified logistical barriers, including not knowing where to go, long distances to services, and limited operating hours.

CONCLUSIONS

While logistical barriers might be easily addressed, perceived barriers, including negative staff attitudes and behaviors towards adolescents, require concerted and collaborative efforts by educators, health professionals, and policy makers to change.

Examining general, physical, and mental health disparities between transgender and cisgender adults in the U.S

BACKGROUND

With the proliferation of anti-transgender policies in some U.S. jurisdictions, this study examines the general, mental, and physical health of transgender and cisgender populations.

METHODS

Data from the 2020-2023 Behavioral Risk Factor Surveillance System were analyzed to examine associations between gender identity and health outcomes. Propensity score weighting was used to address potential imbalances among group characteristics. We conducted logistic regression for the binary outcome of self-rated health and quasi-Poisson regression for the number of days reporting poor mental and physical health.

RESULTS

Results reveal significant disparities in health outcomes, with transgender individuals reporting lower proportions of good general health and more days of poor mental and physical health compared to cisgender individuals. In the adjusted analyses, transgender individuals were significantly less likely to report good general health compared to cisgender peers (OR = 0.60, 95% CI = 0.52-0.69). Gender nonconforming (GNC), male-to-female (MTF), and female-to-male (FTM) individuals had lower odds of reporting good general health compared to cisgender individuals (GNC, OR = 0.46, 95% CI = 0.35-0.61; MTF, OR = 0.67, 95% CI = 0.53-0.85; FTM, OR = 0.71, 95% CI = 0.57-0.87). GNC individuals had an 86% higher frequency of poor mental health days (IRR = 1.86, 95% CI = 1.57-2.21) and a 37% higher frequency of poor physical health days (IRR = 1.37, 95% CI = 1.15-1.63) compared to cisgender counterparts. Similarly, MTF and FTM individuals had significantly higher frequencies of poor mental and physical health days.

CONCLUSIONS

The study highlights significant health disparities faced by transgender individuals, who report poorer general, mental, and physical health. These findings underscore the need to address the unique challenges and improve health outcomes within the transgender community.

Unpacking the Association Between Food Insecurity and Mental Health Disorders Among Older Adults

OBJECTIVES

Previous research shows a negative correlation between food insecurity and mental health, but limited exploration exists among older adults. This study examines this association in Canadian adults aged 65 and older, focusing on the mediating roles of perceived life stress and community belonging, and the moderating role of gender.

METHODS

Cross-sectional data from the 2017-2018 Canadian Community Health Survey (n = 28,044) were analyzed using logistic regression.

RESULTS

The associations between food insecurity and both anxiety and mood disorders were partially mediated by high life stress and low community belonging. The adverse associations of food insecurity, high life stress, and low community belonging with an anxiety disorder were more pronounced in women than in men. Similar patterns were observed for a mood disorder.

DISCUSSION

Interventions should address food insecurity, life stress, and community belonging, with particular attention to the unique challenges faced by older women to improve mental health.

Psychometric validation of the continuum beliefs of mental illness scale (CB-MIS) and its associations with stigma

BACKGROUND

Continuum beliefs of mental health and illness are robustly negatively correlated with mental illness stigma. However, there is a lack of multidimensional and validated measures, not entirely relying on vignettes.

METHODS

To develop such a scale, a pool of 37 items adapted from other studies on continuum beliefs, was initially examined in expert discussions and a convenience sample (N = 227, Mage=32 years, 80.6% female). Items were selected based on theoretical tenability and assigned to pre-defined facets of "State", "Person", and nosological "Concept" in relation to mental illness. In a second sample (N = 1375; Mage=42 years; 65.2% female), the Continuum Beliefs of Mental Illness Scale (CB-MIS) was psychometrically tested (i.e. factorial, convergent, discriminant validity).

RESULTS

The scale comprises three subscales with three items, and one optional vignette-based item each, rated on a 5-point Likert scale. It showed very good factorial and discriminant validity, associations with stigma were moderately negative. The scale exhibited good test-retest reliability over a period of six months.

CONCLUSIONS

A validated, practical, multifaceted measure is offered to evaluate beliefs regarding the continuum of mental health and illness. Future studies should conduct subgroup-specific investigations regarding sociodemographic and illness variables, and could apply this measure to anti-stigma interventions.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00023557. Registered 11/12/2020. World Health Organization, Universal Trial Number: U1111-1264-9954. Registered 16/02/2021.

Racism, discrimination, medical mistrust, stigma, and lung cancer screening: a scoping review

OBJECTIVE

Lung cancer screening can reduce lung cancer-specific mortality, but it is widely underutilized, especially among minoritized populations that bear a disproportionate burden of lung cancer, such as Black Americans. Racism, discrimination, medical mistrust, and stigma contribute to lower uptake of preventive screenings in general, but the role these factors play in lung cancer screening is unclear. We therefore conducted a scoping review to synthesize the literature regarding how racism, discrimination, medical mistrust, and stigma relate to lung cancer screening.

DESIGN

Informed by PRISMA-ScR guidelines, we searched five databases for relevant literature, and two trained researchers independently reviewed articles for relevance. We conducted a narrative, descriptive analysis of included articles.

RESULTS

A total of 45 studies met our inclusion criteria. Most articles reported on medical mistrust or one of its cognates (e.g. trust and distrust, n = 37) and/or stigma (n = 25), with several articles focusing on multiple constructs. Few articles reported on racism (n = 3), and n = 1 article reported on discrimination. Results from empirical studies suggest that medical mistrust, distrust, and stigma may be barriers to lung cancer screening, whereas trust in health care providers may facilitate screening. The articles reporting on racism were commentaries calling attention to the impact of racism on lung cancer screening in Black populations.

CONCLUSIONS

Overall, novel interventions are needed to promote trust and reduce mistrust, distrust, and stigma in lung cancer screening initiatives. Dedicated efforts are especially needed to understand and address the roles that racism and discrimination may play in lung cancer screening.

CARE-SD: classifier-based analysis for recognizing provider stigmatizing and doubt marker labels in electronic health records: model development and validation

OBJECTIVE

To detect and classify features of stigmatizing and biased language in intensive care electronic health records (EHRs) using natural language processing techniques.

MATERIALS AND METHODS

We first created a lexicon and regular expression lists from literature-driven stem words for linguistic features of stigmatizing patient labels, doubt markers, and scare quotes within EHRs. The lexicon was further extended using Word2Vec and GPT 3.5, and refined through human evaluation. These lexicons were used to search for matches across 18 million sentences from the de-identified Medical Information Mart for Intensive Care-III (MIMIC-III) dataset. For each linguistic bias feature, 1000 sentence matches were sampled, labeled by expert clinical and public health annotators, and used to supervised learning classifiers.

RESULTS

Lexicon development from expanded literature stem-word lists resulted in a doubt marker lexicon containing 58 expressions, and a stigmatizing labels lexicon containing 127 expressions. Classifiers for doubt markers and stigmatizing labels had the highest performance, with macro F1-scores of 0.84 and 0.79, positive-label recall and precision values ranging from 0.71 to 0.86, and accuracies aligning closely with human annotator agreement (0.87).

DISCUSSION

This study demonstrated the feasibility of supervised classifiers in automatically identifying stigmatizing labels and doubt markers in medical text and identified trends in stigmatizing language use in an EHR setting. Additional labeled data may help improve lower scare quote model performance.

CONCLUSIONS

Classifiers developed in this study showed high model performance and can be applied to identify patterns and target interventions to reduce stigmatizing labels and doubt markers in healthcare systems.

Relationship between suicide ideation and attempts, bully victimization, dating violence, and depressive symptoms among Black and Hispanic youth

BACKGROUND

Suicide rates among Black and Hispanic youth have been increasing over the past decade in the United States. The objective of this study was to identify risk factors for suicide ideation and attempt among Black and Hispanic youth in the United States using intersectionality theory and minority stress theory as a framework.

METHODS

Data from the CDC Youth Risk Behavior Surveillance System (YRBSS; 2015-2019) were analyzed and delimited to include only Black and Hispanic youth.

RESULTS

About 37% of the subsample identified as Black and 63% of the subsample identified as Hispanic; mean age was 16 years (SE = 0.02). Weighted multivariate logistic regressions were used to explore associations between suicide ideation and attempt, depressive symptoms, bullying, dating violence, and being threatened with a weapon. Black and Hispanic youth who had depressive symptoms, experienced bullying, dating violence, or threatened with a weapon all had increased odds of having suicide ideation and suicide attempt. Hispanic youth had the higher odds of suicide ideation and attempt than Black youth. Girls in the study also had elevated odds of suicide ideation.

CONCLUSION

This study adds to the literature on risk factors of suicide in Black and Hispanic youth and bringing to awareness the gender disparities in suicide ideation and attempt among youth.

Contextual variation in the effect of unemployment on subjective wellbeing in the United States

Becoming unemployed is a disruptive event with negative consequences for psychological wellbeing. Yet, the harmful effect of unemployment might vary depending on the social context. The literature offers two opposing hypotheses about contextual variation: The economic strain approach suggests that becoming unemployed is more harmful during an economic downturn because of reduced employment opportunities and sources of support. In contrast, the social normativity approach suggests that unemployment is less harmful when unemployment is pervasive because of reduced stigma, shame, and guilt. We examine contextual variation in the effect of unemployment in the United States using longitudinal data and individual fixed effects models. We find a U-shaped pattern of contextual variation. The effect of unemployment on psychological wellbeing is smaller at very low and very high state unemployment rates and larger at moderate state unemployment rates. The decline in the harmful effect of unemployment as aggregate unemployment rises from moderate to high is consistent with the normativity hypothesis. While some variation exists across specifications, differences across aggregate levels of unemployment are significant in our preferred specifications. This pattern is similar across gender, suggesting that normative expectations about employment are relatively similar for men and women in the early 21st century. The impact of unemployment on subjective wellbeing depends on how prevalent and normative the experience of unemployment is in society.

Development of the Migraine-Related Stigma (MiRS) Questionnaire: Results of the OVERCOME (US) Study

BACKGROUND

Stigma is emerging as an important social contributor to migraine-related disability and other outcomes. Currently, there are no published validated measures of migraine-specific measures of stigma.

OBJECTIVES

This secondary post hoc analysis of a cross-sectional cohort study aimed to develop a questionnaire to evaluate migraine-related stigma.

METHODS

Based on focus group discussions among persons with migraine and literature review, a panel of migraine experts iteratively developed 12 candidate items for the migraine-related stigma (MiRS) questionnaire, which aims to measure if and how people living with migraine perceive they are viewed in a stigmatizing manner by others. The United States ObserVational survey of the Epidemiology tReatment and Care Of MigrainE (OVERCOME) study identified people with active migraine within a demographically representative United States (US) adult sample and administered the novel MiRS questionnaire in addition to questionnaires assessing sociodemographics, monthly headache days, and migraine disability score (Migraine Disability Assessment) among other data. Exploratory factor analysis was then utilized to evaluate the structure of the MiRS items and determine the Cronbach's alpha described internal consistency of the factors.

RESULTS

This exploratory factor analysis was a secondary post hoc analysis of a cross-sectional cohort study derived from the OVERCOME population-based web survey, which was conducted in a United States sample of 61,932 adults with migraine. The mean (standard deviation) age was 41.7 (14.8) years, 74.5% (n = 46,122) were female, and 70.3% (n = 43,564) identified as White. Two factors were identified: MiRS-external perception of Secondary Gain (eigenvalue = 21.5, percentage of total variance = 88.9%) and MiRS-external perception of Minimizing Burden of migraine (eigenvalue = 2.7, percentage of total variance = 11.1%). The two factors were correlated (r = 0.66) and a non-orthogonal varimax rotation showed that eight items loaded onto the MiRS-Secondary Gain factor, and four items loaded onto the MiRS-Minimizing Burden factor.

CONCLUSION

This population-based study of >60,000 people with migraine allowed the development and validation of the first migraine-specific measure of perceived external stigma for people with migraine. This study demonstrated that MiRS consists of two internally consistent subscales: Secondary Gain and Minimizing Burden. This may be a useful tool for quantifying perceived migraine-related stigma to understand determinants of migraine-related stigma and test interventions to reduce perceived migraine-related stigma.

Lessons learned from syndemic HIV research in an immigrant, latinx sexual and gender minority community

The HIV incidence rate in Miami-Dade County is among the highest in the United States, with Latinx sexual and gender minority (SGM) groups experiencing a disproportionate burden. Despite extensive efforts by both private and public sectors to curb transmission and improve pre-exposure prophylaxis (PrEP) uptake, Latinx SGM groups continue to have high rates of HIV and low PrEP uptake compared to SGM groups overall. Using data collected from a biobehavioral study of the socio-structural factors affecting HIV susceptibility and PrEP uptake among Latinx SGM subgroups in Miami-Dade County, this paper shares lessons learned and provides concrete recommendations for tailoring survey research and biospecimen collection among a largely immigrant, socioeconomically disadvantaged community that is especially vulnerable to HIV. By drawing inferences from study data and contextualizing these with community partners, we learned: (1) Large parts of the target community may be unfamiliar with the underlying constructs captured in important HIV-related measures; (2) Cash incentives may shift motivation from intrinsic to extrinsic and lead to poorer data quality; (3) Deviations in Spanish go beyond vocabulary used in different Latin American countries, and more formal Spanish may relay concepts in unfamiliar ways that are unapproachable; and (4) community members may be unfamiliar with survey data collection processes and the protections in place to ensure confidentiality. These lessons and associated recommendations may help improve recruitment, study design, analysis, and community engagement in future studies, building trust and ultimately reducing the burden of HIV in these communities.

Lack of Follow-Up in a Food-Insecure Population

Literature regarding attendance in elective health programs, like the Geaux Get Healthy Clinical Program at Our Lady of the Lake (OLOL), is scarce. This study aimed to investigate reasons for the non-enrollment of eligible, food-insecure individuals from Baton Rouge in the Geaux Get Healthy Clinical Program at Our Lady of the Lake (OLOL), which is a clinic-based community program addressing food insecurity. A prospective qualitative study was conducted using semi-structured phone interviews with 19 participants screened for food insecurity within the Franciscan Missionaries of Our Lady Health System (FMOLHS) but who did not enroll in the program. Interviews were recorded, transcribed, and analyzed thematically. Demographic data were extracted from the Epic database and statistically analyzed. The participants, primarily African-American females, cited a lack of awareness as the main reason for non-enrollment. Other barriers included embarrassment, transportation difficulties, and competing priorities. This study highlights the importance of addressing barriers to participation in community health programs like Geaux Get Healthy. Enhancing awareness and mitigating obstacles can improve program enrollment and ensure better use of resources to positively impact the health outcomes of food-insecure populations.

Experiences with HIV stigma, among other barriers, in oral healthcare settings in Türkiye

Oral healthcare settings can be a challenging environment for people with HIV. Combined with problematic insurance policies, insufficient health literacy, and higher treatment fees, HIV stigma contributes to barriers when accessing oral healthcare. We conducted a descriptive study via an online survey with open-ended questions to understand the experiences of people with HIV in oral healthcare settings. The survey was administered by non-governmental organizations. Thematic analysis was used to analyze the data via a critical realist approach. Seventy-five participants responded to survey between August and September 2023. Thematic analysis yielded three main themes: occurrences of stigma in healthcare, coping with HIV stigma and anxiety, and barriers beyond stigma. Participants reported a problematic understanding of HIV literature and stigma among dentists, which was manifested as excessive precaution measures, denial of care, unnecessary referrals, gossiping, discriminatory remarks and disclosure of HIV status without consent. This was reflected in people with HIV as self-stigma, fear of healthcare workers and avoidance of healthcare services. Advancements in dental education and post-qualification training are needed in infection control and ethics, while people with HIV need health education to preserve their rights and sustain good health and well-being to prevent adverse outcomes.

Caregivers' Perspectives on Supporting Sexual and Gender-Diverse Youth in Adolescent Relationship Abuse Prevention

Adolescent relationship abuse (ARA) has significant sequelae and is more prevalent among sexual and gender-diverse youth (SGDY). Increased parental involvement and communication has been linked to decreased prevalence of ARA and associated health risks. Parents of SGDY may have unique needs and experiences regarding communicating with their children about ARA, yet little research has examined this area. This study explored caregivers' current practices around supporting their SGDY in healthy relationship formation and ARA prevention; caregivers' perceptions about ARA among SGDY; and their recommendations for developing ARA prevention-focused interventions for caregivers of SGDY. We conducted 24 semi-structured interviews with caregivers of SGDY aged 12 to 19. Transcripts were analyzed using thematic analysis. Some participants reported having positive, open communication with their SGDY about dating, while others struggled to understand and respond to the unique risks of ARA experienced by their adolescent. Caregivers discussed ways systemic discrimination affects SGDY experiences of relationships and ARA, and distinct dating challenges for gender-diverse youth. When considering caregiver-focused ARA prevention, participants supported a program including ARA education, communication skills building, and caregiver affirmation. Participants encouraged the use of digital and in-person mediums, experienced and relatable facilitators, and SGDY involvement. Caregivers of SGDY had significant strengths and challenges when engaging and communicating with their child around dating and ARA prevention. Caregivers at varying stages of acceptance and understanding believed they could benefit from a comprehensive and inclusive education program on SGDY ARA experiences and how they can support their child in preventing ARA.

How Weight Bias and Stigma Undermine Healthcare Access and Utilization

PURPOSE OF REVIEW

To highlight recent evidence of the impact of weight bias and stigma on healthcare access and utilization.

RECENT FINDINGS

Healthcare access for patients with obesity is limited by weight-discriminatory policies such as body mass index cutoffs and weight loss requirements. These policies are based on flawed justifications without demonstrated medical benefits. Healthcare providers continue to hold negative views of patients with obesity, but recent evidence does not suggest that providers' weight-stigmatizing attitudes affect obesity treatment referrals. With the rise of new anti-obesity medications, more research is needed to understand how weight stigma may or may not affect providers' prescribing behavior and patients' access to this form of treatment. Experienced, anticipated, and internalized weight stigma is associated with patients' avoidance of healthcare and reduced utilization. Weight bias and stigma limit healthcare access and utilization. Structural changes are needed to remove weight-discriminatory barriers to care.

"The more I think about it, the less I like it": Effects of elaboration, narrative transportation, and freedom threat on the effectiveness of HPV vaccination advocacy messages

Approximately 80 million US adults-one in four-are infected with the human papillomavirus (HPV), which causes cancers of the cervix in women, cancers of the anus, penis, and throat in men, and genital warts in both sexes. Although HPV vaccinations are safe, effective, easily affordable, and readily available, a substantial percentage of parents resist recommendations to vaccinate their children against HPV. The current study tests the effects of different vaccination advocacy message strategies on attitudes toward HPV vaccination. Study participants (N = 963) were randomly assigned to one of four message conditions (a narrative story, an informational fact sheet, an appeal from an expert spokesperson, or an identical appeal from a nonexpert spokesperson) and assessed for change in attitude toward HPV vaccination along with levels of elaboration, narrative transportation, and freedom threat caused by the messages. Analyses showed that the messages' effects on attitude change were mediated by transportation and moderated by freedom threat. With the informative, expert, and nonexpert messages, increased message engagement produced increased freedom threat. With the narrative message, increased message engagement produced reduced levels of freedom threat. For risk communicators and planners of health interventions, the results suggest benefits for using a nonexpert advocacy message when levels of message engagement are expected to be low and using a story-based narrative advocacy message when levels of message engagement are expected to be high.

Employment Nondiscrimination Protection and Mental Health Among Sexual Minority Adults

Importance

In the 2020 Bostock v Clayton County decision, the US Supreme Court extended employment nondiscrimination protection to sexual minority adults. The health impacts of this ruling and similar policies related to sexual orientation-based discrimination are not currently known.

Objective

To estimate changes in mental health following the Bostock decision among sexual minority adults in states that gained employment nondiscrimination protection (intervention states) compared with those in states with protections already in place (control states).

Design, Setting, and Participants

This cross-sectional study used 2018-2022 data from the Behavioral Risk Factor Surveillance System and a difference-in-differences approach to evaluate changes in mental health after the Bostock decision by comparing sexual minority adults (aged ≥18 years and identifying as lesbian, gay, or bisexual) in 12 intervention states with those residing in 9 control states. Models were estimated for all participants and separately for employed participants. Data were analyzed between February and September 2024.

Exposure

Residing in a state that gained employment nondiscrimination protection after the Bostock decision.

Main Outcomes and Measures

The primary outcome was number of poor mental health days during the past 30 days, and the secondary outcome was severe mental distress (defined as 14 or more past-month poor mental health days).

Results

Of 597 462 participants (306 365 in intervention states [77.7% aged 18-64 years and 22.3% aged ≥65 years; 51.7% female] and 291 097 in control states [77.5% aged 18-64 years and 22.5% aged ≥65 years; 50.6% female]), 5.1% in intervention states and 6.0% in control states self-identified as sexual minority adults. The mean (SE) number of past-month poor mental health days was unchanged after the Bostock decision among sexual minority adults in both intervention (from 8.70 [0.27] to 9.59 [0.24] days; adjusted difference, 0.57 [95% CI, -1.02 to 2.16] days) and control (from 8.53 [0.21] to 10.15 [0.20] days; adjusted difference, 1.17 [95% CI, -0.46 to 2.79] days) states, resulting in no differential change between the 2 groups (difference-in-differences, -0.60 days; 95% CI, -1.25 to 0.06 days). Among the subset of employed sexual minority adults, the mean (SE) number of poor mental health days did not change in intervention states (from 7.99 [0.38] to 8.83 [0.30] days; adjusted difference, 0.87 [95% CI, -0.49 to 2.22] days) but increased in control states (from 7.75 [0.27] to 9.75 [0.26] days; adjusted difference, 1.84 [95% CI, 0.44-3.24] days). These findings corresponded to a significant relative reduction in poor mental health days among employed sexual minority adults in intervention vs control states (difference-in-differences, -0.97 days; 95% CI, -1.74 to -0.21 days). Mean (SE) rates of severe mental distress increased less among employed sexual minority adults in intervention (from 26.35% [1.59%] to 29.92% [1.46%]; adjusted difference, 6.81% [95% CI, 2.20%-11.42%]) vs control (from 26.53% [1.27%] to 34.26% [1.16%]; adjusted difference, 10.30% [95% CI, 5.99%-14.61%) states, also corresponding to a significant relative reduction among employed sexual minority adults (difference-in-differences, -3.49%; 95% CI, -6.71% to -0.27%).

Conclusions and Relevance

These findings show significant relative reductions in past-month poor mental health days and severe mental distress among employed sexual minority adults after the implementation of a federal ban on employment discrimination based on sexual orientation. Larger and more consistent mental health benefits observed among sexual minority adults in the workforce underscore the importance of broadening protections to other social domains.

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

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

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

OBJECTIVES

Stigma is known to be a major barrier to treatment for people who use drugs (PWUD). This study uses the Stigma and Health Discrimination Framework to analyze how different forms of stigma shape experiences in the wake of an overdose incident, and perceptions of the efficacy and utility of postoverdose interventions among a sample of PWUD in Dayton, Ohio-a location with a high overdose rate.

METHODS

Interviews were conducted with 23 individuals who self-reported past-month illicit opioid, crack/cocaine, or methamphetamine use who had experienced or witnessed a drug overdose in the past 6 months. Interviews were recorded, transcribed, and thematically analyzed using Taguette software.

RESULTS

Discrete forms of stigma were identified as barriers to postoverdose interventions intended to link PWUD with support and services to help them access treatment. Individuals identified experiences of enacted stigma through medical mistreatment, exploitation, and judgment. They identified anticipated stigma through mistrust and unsustainable treatment. Internalized stigma was identified through the effect of loss on mental health, feeling "stuck," and the role of race on support-seeking behaviors. Experiences of structural stigma included desensitization of addiction as a disease and lack of feasible, long-term treatment options.

CONCLUSIONS

The results suggest that enacted, anticipated, internalized, and structural forms of stigma act as barriers to the efficacy of postoverdose outreach programs, and the initiation and sustainability of treatment. Understanding how each form of stigma adversely impacts PWUD can improve public health and clinical interventions to reduce stigma and overdose death.

Caregivers' Views of a Pediatric Inpatient Intervention to Address Health-Related Social Risks

OBJECTIVE

To understand the experiences of parents and caregivers of hospitalized children with CommunityRx-Hunger, a social care intervention designed to address food insecurity and other health-related social risks (HRSRs). Perspectives on how clinicians can sensitively deliver information about HRSRs in the pediatric inpatient setting were also elicited.

METHODS

In-depth, semistructured qualitative interviews were conducted (April 2022 through April 2023) with caregivers of children hospitalized at an urban academic medical center. Caregivers (N = 23) were purposefully sampled from the intervention arm of the double-blind CommunityRx-Hunger randomized controlled trial (NCT4171999). Initiated during hospital discharge, CommunityRx-Hunger includes 3 evidence-based components: education about HRSRs, delivery of HRSR-related resource information, and ongoing support to boost the intervention over 12 months. Data were analyzed using directed content analysis.

RESULTS

Most caregivers identified as the child's mother (n = 20) and as African American or Black (n = 19) and were partnered (n = 14). Three main themes emerged: (1) positive experiences with CommunityRx-Hunger, including the sentiment that caregivers were unaware of the amount of community resources available to address HRSRs and perceptions that caregivers "were set up for success once we left the hospital"; (2) barriers to integrating social care with medical care, including concern that clinicians "are gonna use [disclosure of HRSRs] against me"; and (3) recommendations for optimizing social care delivery, including a prevalent suggestion to "just give the information" to caregivers, without asking about risks or needs.

CONCLUSION

CommunityRx-Hunger was mostly well received by caregivers. Routinely providing resource information to all caregivers of hospitalized children, regardless of need, could help alleviate concerns about disclosing HRSRs.

Experiences of discrimination in healthcare settings, trust in providers and disordered eating behaviors in LGBTQ+ college students

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals report more experiences of healthcare discrimination and disordered eating behaviors (DEBs), and less trust in physicians than their cisgender and heterosexual counterparts. Although research supports a link between discrimination and DEBs among LGBTQ+ populations, few studies have specifically investigated healthcare discrimination and DEBs in this population. This study examined whether LGBTQ+ status moderated the relation between negative healthcare experiences and DEBs in undergraduates. Undergraduates (n = 322) from a Southeastern (United States) university completed measures of healthcare discrimination, trust in physicians, and DEBs. Analyses investigated whether LGBTQ+ status moderated the relation between healthcare discrimination and DEBs; trust in physicians and DEBs. LGBTQ+ individuals (35% of sample), reported less trust in physicians (p < .001), and more body dissatisfaction (p = .007) and shape/weight overvaluation (p = .008). Among all undergraduates, experiences of healthcare discrimination were associated with higher body dissatisfaction (p = .003) and shape/weight overvaluation (p = .008). Less trust in physicians was associated with greater shape/weight overvaluation (p = .005). LGBTQ+ status did not moderate either relation. It is important to reduce healthcare discrimination and foster patient-provider trust for all young adults. Future research should examine factors influencing patient-provider trust among LGBTQ+ individuals.

Disparities in depression and anxiety at the intersection of race and gender identity in a large community health sample

BACKGROUND

Persons of color experience are disproportionately impacted by poor mental health compared to White individuals, as are gender diverse populations relative to cisgender individuals. Yet, few studies have assessed differences in common mental health disorders at the intersection of race and gender identity.

METHODS

Using health record data from an urban US community health center in Massachusetts that primarily serves LGBTQIA + communities, we organized patients (N = 29,988) into 24 race and gender identity categories, pairing four race groups (White, Black, Asian, and another race, which was inclusive of Native American/Alaskan, Native Hawaiian, Multiracial, and other) with six gender identity groups (cisgender men and women, transgender men and women, nonbinary individuals assigned male and female at birth [AMAB/AFAB]). We compared the severity of self-reported symptoms of depression and anxiety and the likelihood of meeting diagnostic thresholds across the four race categories within three gender groups (cisgender and transgender men, cisgender and transgender women, nonbinary individuals).

RESULTS

Depression and anxiety symptom severity differed within men and women; transgender men and women across races had higher severity than cisgender men and women. In nonbinary individuals, symptom severity was high and consistent across the race groups. Differences were observed in the likelihood of meeting clinical thresholds for depression and anxiety across races in men and women, reflecting the pattern described above. Nonbinary participants across races had high likelihood of meeting the thresholds for both diagnoses (29.2%-47.1%). The likelihood of meeting the depression and anxiety thresholds were highest among Black nonbinary AFAB adults (44.4%) and transgender women in the another race category (48.7%), respectively.

CONCLUSION

In this unique sample, differences in depression and anxiety symptom severity and likely diagnoses suggest disparities among nonbinary individuals across races, as well as among transgender men and women grouped into the another race category and women who identify as Black. Focused mental health strategies tailored to address race and gender identity may be critical to proactively address these disparities.

A Pilot Study on the Freelisting Method Among Adolescents with Chronic Musculoskeletal Pain: Feasibility, Acceptability and Study Findings

Background/Objectives: To assess the feasibility and acceptability of freelisting for adolescents with chronic musculoskeletal pain (CMP) and use freelisting to identify how adolescents with CMP cope with pain. Methods: This was a mixed-methods cross-sectional single-center study of patients 12-18 years old, diagnosed with CMP. Twenty-seven subjects participated in an interview which included the freelisting exercise, probing questions, Connor-Davidson Resilience Scale 10-item, and semi-structured interview. Feasibility was pre-defined as ≥85% completion. A list of 'standardized' freelisting terms was created, and we calculated Smith's salience index. Freelisting terms were grouped into individual, family, friends, school, and medical domains. Results: In this predominantly female population, resilience levels were low to moderate, and on average, participants had moderate pain intensity and functional disability. The freelisting exercise was feasible and acceptable among females, with low recruitment of males. Salient words to describe adolescents' pain included frustrating, upsetting, annoying, and painful. Participants identified family, friends, teachers, guidance counselors, and health professionals as key sources of support. Many participants reported difficulties communicating their pain. Helpful coping strategies included rest, distraction, relaxation, endurance, and extracurricular participation. Conclusions: Freelisting was well perceived among female adolescents with CMP. Supportive relationships with community members play an important role for this population. However, perceived stigma may deter female adolescents from talking about their pain. Purposive sampling of male participants and recruitment strategies ensuring diverse patient representation are necessary to ensure generalizability of future results when using the freelisting method for adolescents with CMP.

The use and operationalization of "structural stigma" in health-related research: A scoping review

BACKGROUND

Research that investigates the negative health effects of stigma beyond the individual and interpersonal levels is increasingly using the concept of "structural stigma." This scoping review investigates how the concept of "structural stigma" has been used and operationalized in health-related literature to date in order to characterize its usage and inform future operationalizations.

METHODS

A systematic search and screening process identified peer-reviewed, English-language research articles that used the term "structural stigma" available prior to January 1, 2024 in five databases (i.e., PubMed, PsycINFO, Embase, Web of Science, CINAHL).

RESULTS

Of the 298 articles identified, over half (53%) were published from 2021 onward. Articles most commonly were set in the United States (n = 163, 55%), investigated stigma toward sexual minority people (n = 163, 55%), and cited the introduction of a special issue of Social Science & Medicine as their source of the concept (n = 84, 28%). Most articles (64%) used at least one additional conceptual framework, most commonly minority stress theory (n = 107, 36%). Quantitative operationalizations (n = 102) engaged most in the conceptual domain of laws and government-level policies, while qualitative operationalizations (n = 68) engaged most with institutional (i.e., non-government-level) policies, practices, and procedures.

CONCLUSIONS

As the use of "structural stigma" is increasing, operationalizations can better leverage the concept's breadth and account for individuals' intersectional lived experiences. This will necessitate bridging across methodologies and bodies of research on related negative social processes.

Exploring the impact of stigma on health-related quality of life among individuals with sickle cell disease: a moderated mediation analysis of distress and social support

Despite extensive research on the impact of stigma on the health-related quality of life (HRQoL) of people with sickle cell disease, gaps remain in understanding the mechanisms through which this association occurs. We investigated how stigma impacts HRQoL among people with sickle cell disease (SCD) through distress and the moderating role of social support in this association. Utilizing a cross-sectional design, we sampled 165 people with SCD in Nigeria, who completed relevant measures. Results showed that distress mediated the stigma-HRQoL link, and social support moderated this mediation. Intervention may do well to incorporate psychological therapies and strengthen social support networks to improve the HRQoL of people living with sickle cell disease.

Decrease in provider stigma is associated with improved quality health indicators among individuals receiving methadone in primary care centers in Ukraine

INTRODUCTION

People who inject drugs experience poor health and social outcomes which improve with opioid agonist therapies like methadone, yet provider stigma may influence healthcare utilization. In Ukraine, integrating methadone into primary care centers (PCCs) provides an opportunity to examine provider stigma and its impact on patient outcomes.

METHODS

This sub-analysis included patients randomized to receive methadone in PCCs as part of an implementation trial in which the control group received methadone in specialty addiction clinics in Ukraine. Methadone integration in PCCs was supported through continuous tele-education for providers. Provider stigma towards people who inject drugs, methadone, and attitudes towards evidence-based practices were assessed at baseline, 12, and 24 months using standardized scales (range 1-10). Patient-level outcomes were measured bi-annually over 24 months using a quality health indicator (QHI) score, a percentage of guideline-concordant primary and specialty health services accessed. Linear mixed-effects models examined the changes in provider stigma and attitudes, and the association of these measures with patient outcomes.

RESULTS

The sample included 583 patients and the 112 providers in 24 clinics. Provider fear and stereotypes toward people who inject drugs improved significantly, by 0.6 (95 % CI 0.2-1.1) and 0.4 points (95 % CI 0.1-0.8), respectively, as did preference for methadone over abstinence-based treatment (0.7 points, 95 % CI 0.2-1.1). A 1-point improvement in provider prejudice correlated with a 7.0-point increase (95 % CI: 1.1-13.0) in patient primary care QHI scores at 12 months, while improved attitudes towards evidence-based practices were associated with an 8.3-point increase (95 % CI: 1.1-13.0). Preference for methadone maintenance over abstinence was associated with a 3.7-point increase (95 % CI: 0.6-6.7) in specialty care QHI scores at 12 months, and reduced stereotypes were associated with a 10.9-point increase (95 % CI: 1.2-20.7) at 24 months.

CONCLUSIONS

Integrating methadone into PCCs with the support of provider tele-education may reduce provider stigma, particularly fear and stereotypes, toward people who inject drugs and methadone maintenance. Reducing provider stigma has the potential to improve patient outcomes through increased access to preventive care and screenings.

Socio-economic factors associated with cancer stigma among apparently healthy women in two selected municipalities Nepal

INTRODUCTION

Cancer is the primary cause of death globally, and despite the significant advancements in treatment and survival rates, it is still stigmatized in many parts of the world. However, there is limited public health research on cancer stigma among the general female population in Nepal. Therefore, this study aims to determine the prevalence of cancer stigma and its associated factors in this group.

METHODS

We conducted a cross-sectional study among 426 healthy women aged 30 to 60 years who were residents of Dhulikhel and Banepa in central Nepal. We measured cancer stigma using the Cancer Stigma Scale (CASS). CASS measures cancer stigma in six domains (awkwardness, avoidance, severity, personal responsibility, policy opposition, financial discrimination) on a 6-point Likert scale (strongly disagree to agree strongly) with higher mean stigma scores correlating with higher levels of stigma. We utilized Generalized Estimating Equations (GEE) with multivariable linear regression to identify the socio-demographic factors associated with the CASS score.

RESULTS

Overall, the level of cancer stigma was low, with a mean stigma score of 2.6 (0.6), but it was still present among participants. Stigma related to personal responsibility had the highest levels, with a mean score of 3.9 (1.3), followed by severity with a mean score of 3.2 (1.3), and financial discrimination with a mean score of 2.9 (1.6). There was a significant association between the mean CASS score and older age (mean difference in stigma score: 0.11 points; 95% CI: 0.02-0.20) as well as lower education (difference: -0.02 points; 95% CI: -0.03 to -0.003), after adjusting for age, ethnicity, education, marital status, religion, occupation, and parity.

CONCLUSION

While overall cancer stigma was low, some domains of stigma were higher among women in a suburban area in central Nepal; thus, indicating that cancer stigma persists in this region despite its low overall prevalence.

Gambling harms, stigmatisation and discrimination: A qualitative naturalistic forum analysis

People who experience gambling harms commonly experience stigmatisation, which is detrimental to psychological wellbeing, and a significant barrier to help-seeking. While there have been efforts to challenge stigmatisation, there is little empirical evidence available to inform such initiatives. To address this gap in knowledge, we conducted a thematic analysis of naturalistic data in the form of posts made on online support forums by people with experience of gambling-related harm, in order to understand how they are stigmatised, and to identify barriers to help-seeking. Five main themes were identified: (a) beliefs about the nature and origin of gambling addiction, which related to participants' beliefs about causes of gambling harm and cognitions about the nature of addiction; (b) self-stigma, which encompassed the frequent and substantial incidences of self-stigma; (c) anticipated stigma, which described the stigma and discrimination people expected to face because of their gambling harm; (d) stigmatising other people who experience gambling harm, which describes the ways in which some people who experienced gambling harms stigmatised other people who experienced gambling harms; and (e) experienced stigma and discrimination, which encompassed the experienced stigmatisation people encountered. Experiences discussed/described within the forums were developed into a timeline of gambling harms which was cyclical in nature and involved six stages: onset, concealment of problems, crisis point, disclosure of problems, recurrence of harms (sometimes termed 'relapse') and recovery. The study highlights the impact of societal stigma on individuals' self-perception and interactions, particularly emphasising the challenges experienced during relapse periods, which heighten stigma and distress. The study also identifies potential avenues for stigma reduction, including targeted campaigns addressing societal, anticipated, and self-stigma.

Structural and political determinants of health among Syrian refugee young adults in the Bekaa, Lebanon: a prospective cohort study of the impact of security raids on perceived discrimination and well-being

OBJECTIVES

In this work, which forms part of a larger study of a longitudinal intervention focused on empowering Community Mental Health Workers in a humanitarian context, we examine changes in and correlates of well-being of refugees as a result of discriminatory practices by the State, with comparisons motivated by a mechanistic model of well-being.

DESIGN

This cohort study examines well-being at a single follow-up time as predicted by baseline characteristics in response to a changing social conditions including security raids on our participants; the parent interventional randomised trial focuses on a population of youth in a refugee context, but the present work precedes the main intervention period.

SETTING

Refugee populations are among the most vulnerable globally, and the total refugee population is growing dramatically. As of 2022, more than 12 million Syrians have been forcibly displaced with 6.5 million of them classified as refugees. In Lebanon specifically, tension between refugees and the host government has recently risen most evident through security raids, threatening the well-being of already displaced persons.

PARTICIPANTS

The study recruited Syrian refugee young adults (18-24 years) who have completed at least high school; additional inclusion criteria included: living in the catchment areas within the Bekaa at the time of screening, having been involved in non-governmental organisations (NGOs) or service to their community and having expressed motivation to serve their community. Applicants who fit the inclusion criteria were further screened by a psychiatrist to ensure that they were not experiencing acute distress at the time of recruitment (February 2023-March 2023). Recruitment occurred through posters on social media platforms of Multi-Aid Programmes. Ninety-two young adults were randomly assigned to one of the three randomised controlled trial arms.

INTERVENTIONS

None at the time of the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were measures of well-being at baseline and follow-up.

RESULTS

We find that the ability of NGOs to work with refugee populations may be threatened in important ways by government security raids, with possibly the most vulnerable subjects participating at baseline being less likely to respond during the raids. Moreover, we discuss the paradoxical short-term effects of the isolation induced by the raids, where daily experience of stigmatising events actually decreased during this period.

CONCLUSIONS

These results highlight the challenging environment in which refugees in Lebanon live in, and raise important questions about long-term solutions to the crisis.

TRIAL REGISTRATION NUMBER

NCT05265611; LBCTR2023015206.

Material, Psychological, and Behavioral Financial Hardship Among Lesbian, Gay, and Bisexual Cancer Survivors in the United States

PURPOSE

Driven by anti-LGBTQ+ stigma, emerging literature suggests that lesbian, gay, and bisexual (LGB) cancer survivors experience financial hardship (FH) more frequently than heterosexual survivors. However, few studies have used nationally representative samples to estimate this inequity.

METHODS

National Health Interview Survey data from 2019 to 2022 were pooled and weighted. Outcomes included material, psychological, and behavioral FH. The behavioral domain was further broken down into subdomains including medical care, prescription medications, and mental health care. Multivariable logit models controlling for a variety of factors were used to generate LGB and heterosexual predicted probabilities and differential effects for each FH outcome. Stratified estimates were generated by sex and age groups.

RESULTS

A total of N = 374 LGB and N = 12,757 heterosexual cancer survivors were included in this analysis. In adjusted analyses, LGB cancer survivors had significantly higher material (19%, 95% CI, 15 to 24 v 12%, 95% CI, 11 to 13; P = .004), psychological (44%, 95% CI, 38 to 51 v 37%, 95% CI, 36 to 38; P = .035), and behavioral (23%, 95% CI, 18 to 28 v 13%, 95% CI, 13 to 14; P < .0001) FH than heterosexual survivors. LGB cancer survivors also had higher medical behavioral (11%, 95% CI, 7 to 15 v 7%, 95% CI, 6 to 7; P = .030), prescription medication behavioral (14%, 95% CI, 10 to 19 v 10%, 95% CI, 9 to 10; P = .032), and mental health behavioral (9%, 95% CI, 6 to 13 v 3%, 95% CI, 3 to 4; P < .0001) FH than heterosexual survivors. Stratified estimates revealed young LGB cancer survivors had the highest probability of each outcome (material: 31%, 95% CI, 23 to 40; psychological: 58%, 95% CI, 50 to 66; behavioral: 45%, 95% CI, 36 to 53).

CONCLUSION

In this nationally representative analysis, LGB cancer survivors experience substantial inequities in all FH outcomes. It is crucial that future FH interventional work should prioritize populations at the highest risk of FH, such as LGB cancer survivors.

The Synergistic Health Threats of State Laws Targeting Marginalized Groups in the United States

Discriminatory state laws have deleterious effects on the health of socially marginalized groups. Health care clinicians, institutions, researchers, and research funders have tended to view different discriminatory laws in isolation, focusing on particular issues or groups. In contrast, intersectionality calls attention to the overlapping and synergistic systems of oppression that discriminatory legislation promotes or upholds, warranting an integrated analysis of these laws. In this analytic essay, we assess discriminatory state laws simultaneously and discuss their implications for health care clinicians, institutions, and researchers. We present a multifunctional model of law and population health that describes how discriminatory law affects health outcomes among marginalized groups. We then draw on publicly available legislation trackers to identify 30 states that have enacted legislation since 2020 that targets Black people and other people of color; lesbian, gay, bisexual, and queer people; transgender and nonbinary people; and women and other birthing people. Finally, we call for a coordinated, multilateral, and forceful effort by health care professionals, institutions, researchers, and research funders to counter these laws and address their predictable health consequences. (Am J Public Health. 2024;114(12):1335-1343. https://doi.org/10.2105/AJPH.2024.307830).

Multimorbidity and person-centred care in a socioeconomically deprived community: a qualitative study

BACKGROUND

People with multimorbidity (>2 long-term conditions) have poorer outcomes in areas of high socioeconomic deprivation (SED). High-quality person-centred care (PCC) is important in those with multimorbidity, but socially vulnerable populations have not, to our knowledge, informed current PCC models.

AIM

To explore how wider community factors influence management of multimorbidity in the context of high SED, how high-quality PCC is defined by patients, and whether this influences healthcare management.

DESIGN AND SETTING

Ethnographically informed case study in a community experiencing high SED in Scotland.

METHOD

Participant observation (138 h) was undertaken within four community groups who also took part in two participatory workshops. There were 25 in-depth interviews with people with multimorbidity, recruited from local general practices; emerging findings were discussed with interviewees in one focus group. Field notes/transcripts were analysed using inductive thematic analysis.

RESULTS

Key aspects of PCC were 'patient as person', 'strong therapeutic relationship', 'coordination of care', and 'power sharing'; power sharing was particularly enabling but rarely happened (barriers often unseen by practitioners). Shared community experiences of 'being known', 'stigma', and 'none of the systems working' influenced how people approached health services and healthcare decisions. High-quality PCC may have been particularly effective in this setting because of its influence on ameliorating wider shared negative community experiences.

CONCLUSION

In a high SED setting PCC is important and can enhance engagement. Wider community factors have a critical influence on engagement with health care in areas of high SED and PCC may be particularly important in this context because of its influence ameliorating these. Policymakers should prioritise and resource PCC.

Individual & joint associations of sexual stigma and mental distress with PrEP uptake, adherence and persistence among US gay and bisexual men

BACKGROUND

Sexual stigma, mental health disorders, and socioeconomic disparities present important yet incompletely understood barriers to PrEP adoption among gay men and other men who have sex with men (MSM). This study examines how these factors interact and affect PrEP uptake, adherence, and persistence among MSM.

METHODS

Data from the 2018 and 2019 American Men's Internet Survey cycles, involving 6907 adult MSM eligible for PrEP, were analyzed. We assessed sexual stigma heterogeneity among this group using latent class analysis and investigated individual relationships between i) stigma class membership, ii) mental distress, and PrEP engagement (past-year use, adherence, and persistence) using Poisson regression with a robust error variance, considering potential variations based on poverty status. The combined associations of sexual stigma and mental distress with PrEP engagement was evaluated using inverse probability weighting.

RESULTS

Four distinct sexual stigma classes were identified, each exhibiting varied associations with PrEP engagement. Associations with mental distress lost statistical significance after adjusting for confounders. However, having both mental distress and sexual stigma was associated with lower past-year PrEP use, with the strongest association observed for those with anticipated healthcare stigma class membership and mental distress (aPR 0.53 [95% CI: 0.37, 0.76]). Sexual stigma accompanied by mental distress was also associated with significantly increased poor PrEP adherence, particularly among those with family and general social stigma class membership (aPR 2.31 [95% CI: 1.08, 4.97]).

CONCLUSIONS

Psychosocial factors exert synergistic impacts on PrEP engagement among MSM. Tailored interventions addressing these subtleties may effectively optimize PrEP uptake and improve consistency of use among MSM.

The impact of determinants of health on the relationship between stigma and health in people living with HIV

Determinants of health are important drivers of health states, yet there is little work examining their role in the relationship between HIV stigma and health. This study uses moderation analysis to examine how determinants of health affect the relationship between enacted, internalized, and anticipated stigma and mental health. Quantitative data was collected on 337 participants in Ontario, Canada at baseline (t1) between August 2018 and September 2019 and at follow-up (t2) between February 2021 and October 2021. Separate moderation models were created with each determinant of health (age, gender, sexual orientation, ethnicity, geographic region, education, employment, and basic needs) acting as the moderator between types of stigma at t1 and mental health at t2. Age was a significant moderator for the relationship between internalized and enacted stigma at t1 and mental health at t2. Region was a moderator for enacted and anticipated stigma and mental health. Sexual orientation was a moderator for anticipated stigma and mental health. Lastly, having basic needs was a moderator for enacted and anticipated stigma and mental health. Our findings suggest that intervention strategies may be more effective by incorporating supports for these determinants of health in addition to stigma reduction to improve mental health.

Socio-cognitive facilitators of ART-adherence among predominantly black sexual and gender minoritized persons living with HIV in Atlanta, Georgia: a latent profile analysis

The Integrated Change Model describes several social and cognitive factors (e.g., health attitudes, social support, self-efficacy) that can affect medication adherence. Guided by this model, we sought to identify profiles of socio-cognitive facilitators of ART (antiretroviral therapy) adherence among diversely minoritized persons living with HIV enrolled in a behavioral intervention trial in Atlanta, Georgia (N = 477). To do this, we performed latent profile analysis on baseline responses to scales assessing 6 indicators of interest: HIV-care self-efficacy, social support, TasP (treatment-as-prevention) beliefs, trust in healthcare providers, perceived need for ART, and trust in ART. We regressed emergent profiles on internalized, enacted, and microaggressive HIV stigma and compared prospective 30-day ART adherence and several cross-sectional HIV outcomes across profiles. Mean age was 29 years; 83% of participants were non-Hispanic Black, 53% were gay/homosexual-identifying, and 12% were gender expansive. Three profiles emerged: "Constrained/Capable" (6%), featuring high self-efficacy but low-moderate provider trust, social support, TasP beliefs, ART trust, and ART need; "Conflicted" (13%), featuring high TasP beliefs, provider trust, and ART need but moderate self-efficacy, ART trust, and social support; and "Motivated" (81%), featuring high levels of all indicators. Greater internalized, enacted, and microaggressive stigma were positively associated with "Conflicted" relative to "Motivated" profile membership. ART-nonadherence, unsuppressed viral load, and viral load unawareness were more likely for the "Conflicted" relative to the "Motivated" profile. Personalized HIV care tailored to such profiles may improve ART adherence and related outcomes for minoritized persons living with HIV.

Discrimination and Social Exclusion of People Experiencing Mental Disorders in Burkina Faso: A Socio-anthropological Study

Stigma has been pointed out as a barrier to mental healthcare in sub-Saharan Africa. Among the manifestations of stigma, the use of physical restraints is condemned as a form of violation of basic human rights. Research on this phenomenon is limited in West Africa and more particularly in Burkina Faso. This study explores the phenomenon of stigma of individuals experiencing mental disorders in Bobo-Dioulasso (Burkina Faso). As part of 8 months of socio-anthropological fieldwork, we interviewed 94 informants (7 focus groups and 25 individual interviews) to document exclusionary practices, their perceptions, and justifications. Exclusionary practices can be divided in five subgroups: ignoring, physically and sexually abusing, abandoning, banning, and restraining. Some practices were linked to a lack of financial and material resources, while others were justified by an inferior moral status. We observed differences in the type of exclusion experienced between men and women. Restrictive, abusive, and exclusionary measures are common in Bobo-Dioulasso. These practices can either be understood as part of families' adaptative strategies when dealing with chronic conditions, as part of security measures in the case of patients with aggressive behaviors, or as part of punitive measures when transgressions are committed. We conclude the article by addressing the tensions between local and global meanings of stigma.

Conceptual frameworks for the integration of genetic and social epidemiology in complex diseases

Uncovering the root causes of complex diseases requires complex approaches, yet many studies continue to isolate the effects of genetic and social determinants of disease. Epidemiologic efforts that under-utilize genetic epidemiology methods and findings may lead to incomplete understanding of disease. Meanwhile, genetic epidemiology studies are often conducted without consideration of social and environmental context, limiting the public health impact of genomic discoveries. This divide endures despite shared goals and increases in interdisciplinary data due to a lack of shared theoretical frameworks and differing language. Here, we demonstrate that bridging epidemiological divides does not require entirely new ways of thinking. Existing social epidemiology frameworks including Ecosocial theory and Fundamental Cause Theory, can both be extended to incorporate principles from genetic epidemiology. We show that genetic epidemiology can strengthen, rather than detract from, efforts to understand the impact of social determinants of health. In addition to presenting theoretical synergies, we offer practical examples of how genetics can improve the public health impact of epidemiology studies across the field. Ultimately, we aim to provide a guiding framework for trainees and established epidemiologists to think about diseases and complex systems and foster more fruitful collaboration between genetic and traditional epidemiological disciplines.

Socioeconomic-Status-Based Disrespect, Discrimination, Exclusion, and Shaming: A Potential Source of Health Inequalities?

Observing an association between socioeconomic status (SES) and health reliably leads to the question, "What are the pathways involved?" Despite enormous investment in research on the characteristics, behaviors, and traits of people disadvantaged with respect to health inequalities, the issue remains unresolved. We turn our attention to actions of more advantaged groups by asking people to self-report their exposure to disrespect, discrimination, exclusion, and shaming (DDES) from people above them in the SES hierarchy. We developed measures of these phenomena and administered them to a cross-sectional U.S. national probability sample (N = 1,209). Consistent with the possibility that DDES represents a pathway linking SES and health, the SES→health coefficient dropped substantially when DDES variables were controlled: 112.9% for anxiety, 43.8% for self-reported health, and 49.4% for cardiovascular-related conditions. These results illustrate a need for a relational approach emphasizing the actions of more advantaged groups in shaping health inequities.

Mixed evidence for the relationship between HIV stigma and Pain in two studies of people with HIV in Florida

Previous work suggests that HIV stigma is associated with greater pain severity. We sought to characterize this relationship by examining intersectional identities that tend to be stigmatized (i.e., gender; sexual orientation) in two cross-sectional studies of people with HIV (PWH). In Study 1 (N = 840), participants responded to the Enacted Stigma Scale and the Brief Pain Inventory. We found a significant positive association between HIV stigma and pain severity (and between sexual orientation and pain severity), but no interaction effects. In Study 2 (N = 309), participants responded to Internalized Stigma Scale and the Brief Pain Inventory. We did not find a relationship between HIV stigma and pain severity but conceptually replicated the relationship between sexual orientation and pain severity. Results may be due to a small sample size in Study 2, or because the relationship between HIV stigma and pain is specific to enacted stigma (i.e., overt acts of stigma; Study 1) rather than internalized stigma (i.e., an intrapersonal aspect of stigma; Study 2).

Positive, Open, Proud: an adapted disclosure-based intervention to reduce HIV stigma

HIV stigma among people living with HIV (PLWH) is well documented and linked to adverse physical and mental health outcomes among this population. Further, stigma may affect HIV disclosure decisions, which has important individual and public health implications. For women, HIV stigma and disclosure may be compounded by gender-based discrimination and violence. Despite the ill effects of HIV stigma, particularly for women, few evidence-based disclosure interventions to reduce stigma among PLWH exist. However, there is strong evidence for the efficacy of Honest, Open, Proud (HOP), a disclosure-based stigma-reduction intervention for people with mental illness. Given that mental illness and HIV are similar in that they are both stigmatized yet concealable conditions, we propose using the ADAPT-ITT model to adapt HOP into Positive, Open, Proud, a disclosure-based stigma-reduction intervention for PLWH, describing its unique potential for women living with HIV.

An Educational Framework for Healthcare Ethics Consultation to Approach Structural Stigma in Mental Health and Substance Use Health

This paper addresses the need for, and ultimately proposes, an educational framework to develop competencies in attending to ethical issues in mental health and substance use health (MHSUH) in healthcare ethics consultation (HCEC). Given the prevalence and stigma associated with MHSUH, it is crucial for healthcare ethicists to approach such matters skillfully. A literature review was conducted in the areas of bioethics, health professions education, and stigma studies, followed by quality improvement interviews with content experts to gather feedback on the framework's strengths, limitations, and anticipated utility. The proposed framework describes three key concepts: first, integrating self-reflexive practices into formal, informal, and hidden curricula; second, embedding structural humility into teaching methods and contexts of learning; and third, striking a balance between critical consciousness and compassion in dialogue. The proposed educational framework has the potential to help HCEC learners enhance their understanding and awareness of ethical issues related to structural stigma and MHSUH. Moreover, context-specific learning, particularly in MHSUH, can play a significant role in promoting competency-building among healthcare ethicists, allowing them to address issues of social justice effectively in their practice. Further dialogue is encouraged within the healthcare ethics community to further develop the concepts described in this framework.

The Mental Health Impacts of Fuel Poverty: A Global Scoping Review

Objectives

Fuel poverty, defined in this study as a household's inability to meet basic energy needs, presents a significant challenge. We aimed to map research on the impact of fuel poverty on mental health.

Methods

We searched peer review and grey literature repositories. Studies were considered eligible if they focused on both fuel poverty and mental health.

Results

47 studies were included. 64% were published in the last 3 years. 43% focused on the UK sub-geography, with the next most common being Spain (17%) and China (13%). 55% had a quantitative study design. Conceptualisation and operationalisation of fuel poverty varied across studies and contexts. 58% focused on specific vulnerable populations. 46 studies reported evidence of a detrimental association between fuel poverty and mental health. We broadly summarise the role of fuel poverty on mental health under four headings: economic, social, behavioural and environmental.

Conclusion

We highlight a need for clear and explicit conceptualisation of fuel poverty, in conjunction with consideration of pathways connecting fuel poverty to mental health, to advance the field and facilitate research which can improve population health.

"Transgenders are not dinosaurs!" Stigma faced by transgender women in their daily lives in India: implications for research and policy

Background

Transgender women face stigma that adversely impacts their mental wellbeing. The stigma can be self-directed (internal), discrimination, violence and hatred directed towards them by others, mostly cis-gender persons (interpersonal stigma) and discrimination faced at the level of institutional arrangements (structural stigma).

Methods

This was an exploratory study that used qualitative methods of data collection (focused group discussions and in-depth interviews) to gather data from consenting adult trans women who lived in the city of Kolkata situated in the eastern state of West Bengal in India.

Results

The findings showed that trans women faced the trauma of non-acceptance and even rejection by their families when they began to express their chosen gender. Their gender non-conforming behaviour made them the butt of ridicule and harassment in school, resulting in many of them not finishing school. This made finding employment difficult. The trans women study participants also faced harassment at the hands of the police and from hospital staff, making them reluctant to approach the police for help and seek treatment from health providers for their physical as well as mental health concerns.

Conclusions

It is important for researchers to be cognizant of the challenges faced by trans women/transgender people while designing and conducting research. It is also important for policymakers to make gender affirming policies to mitigate and eliminate the stigma that transgender people are subject to thereby promoting their wellbeing.

An integrated empirical and computational study to decipher help-seeking behaviors and vocal stigma

BACKGROUND

Professional voice users often experience stigma associated with voice disorders and are reluctant to seek medical help. This study deployed empirical and computational tools to (1) quantify the experience of vocal stigma and help-seeking behaviors in performers; and (2) predict their modulations with peer influences in social networks.

METHODS

Experience of vocal stigma and information-motivation-behavioral (IMB) skills were prospectively profiled using online surveys from a total of 403 Canadians (200 singers and actors and 203 controls). Data were used to formulate an agent-based network model of social interactions on vocal stigma (self-stigma and social-stigma) and help-seeking behaviors. Network analysis was performed to evaluate the effect of social network structure on the flow of IMB among virtual agents.

RESULTS

Larger social networks are more likely to contribute to an increase in vocal stigma. For small social networks, total stigma is reduced with higher total IMB but not much so for large networks. For agents with high social-stigma and risk for voice disorder, their vocal stigma is resistant to large changes in IMB ( > 2 standard deviations). Agents with extreme IMB and stigma values are likely to polarize their networks faster in larger social groups.

CONCLUSIONS

We integrated empirical surveys and computational techniques to contextualize vocal stigma and IMB beyond theory and to quantify the interaction among stigma, health-seeking behavior and influence of social interactions. This work establishes an effective, predictable experimental platform to provide scientific evidence in developing interventions to reduce health stigma in voice disorders and other medical conditions.

Testing the associations between poverty stigma and mental health: The role of received stigma and perceived structural stigma

BACKGROUND

Previous research has documented how people living on low incomes in the United Kingdom (UK) and internationally experience various forms of poverty stigma. The purpose of this study was to quantitatively examine how experiences of poverty stigma are associated with mental health outcomes.

METHODS

An online, cross-sectional survey was conducted with 1,000 adults living in predominantly low- and middle-income households in the UK. The survey included a questionnaire designed to measure participants' experiences of different forms of poverty stigma, as well as measures of anxiety, depression and mental well-being.

FINDINGS

Exploratory and confirmatory factor analyses of the poverty stigma questionnaire supported a two-factor solution. One factor reflected participants' experiences of being mistreated and judged unfairly by other people because they live on low income (received stigma) and the other factor reflected participants' perceptions of how people living in poverty are treated by media outlets, public services and politicians (perceived structural stigma). Both received and perceived structural stigma were independently associated with anxiety, depression and mental well-being and these relationships persisted after controlling for socioeconomic indicators. There was also evidence that received stigma and perceived structural stigma partially mediated the relationships between financial hardship and mental health outcomes.

DISCUSSION

Experiences of received and perceived structural poverty stigma are both associated with mental health and well-being. This suggests that addressing interpersonal and structural forms of poverty stigma may help to narrow socioeconomic inequalities in mental health.

Exploring stigma experiences of scattered-site public housing residents and its characteristics based on social contact theory

Governments worldwide have been striving to efficiently manage public rental housing. However, the stigma associated with public rental housing persists as a significant challenge. In response, the scattered-site public housing strategy has been introduced as an alternative to traditional large-scale rental housing. The objective of this study was to evaluate the effectiveness of this strategy in reducing the stigma within Seoul metropolitan city. The empirical analysis utilized 2019 Seoul Public Housing Occupant data and a binary logistic regression model. The main findings indicate that residents of scattered-site public housing experience significantly lower levels of stigmatization compared to residents of other public housing types. Notably, the stigmatization experienced by scattered-site public housing residents is lower not only compared to independent public housing residents but also to those in socially mixed public housing, which is typically advantageous for reducing stigmatization. This suggests that residents of scattered-site public housing are statistically more free from both external and internal stigmatization. In addition, a unique characteristic found only in scattered-site public housing is that as residents form closer relationships with their neighbors, they experience more stigmatization. This implies that as scattered-site public housing residents form closer relationships with their neighbors, their identity as public housing residents can become exposed, potentially leading to increased stigmatization.

Investigating changes in mental illness stigma and discrimination after the Time to Change programme in England

BACKGROUND

Between 2008 and 2019, we reported positive change relating to mental health stigma and discrimination among the adult population of England, supporting the effectiveness of the Time to Change campaign.

AIMS

Using data from the Attitudes to Mental Illness survey (2008/2009 to 2023), we investigated the extent to which positive changes in stigma were sustained by 2023, 2 years after the programme's end in 2021.

METHOD

We used regression analyses to evaluate trends in outcomes. Measures were of stigma-related knowledge (Mental Health Knowledge Schedule (MAKS)), attitudes (Community Attitudes toward the Mentally Ill scale (CAMI)) and desire for social distance (Reported and Intended Behaviour Scale (RIBS)). We also examined willingness to interact with people based on vignettes of depression and schizophrenia, and attitudes toward workplace discrimination, using data from the British Social Attitudes Survey for comparison.

RESULTS

CAMI scores improved between 2008 and 2023 (s.d. 0.24, 95% CI 0.16-0.31), but decreased since 2019 (P = 0.015). After improvements between 2009 and 2019, 2023 MAKS and RIBS scores no longer differed from 2009 scores, indicating decreases in stigma-related knowledge (MAKS scores declined 7.8%; P < 0.001) and willingness to interact (RIBS scores declined by 10.2%; P < 0.001) since 2019. Conversely, comparison with British Social Attitudes Survey data indicated that willingness to interact with people with depression and schizophrenia increased gradually between 2007, 2015 and 2023, and attitudes to workplace discrimination also improved.

CONCLUSIONS

The lasting positive changes reflect support for non-discrimination and willingness to interact with someone after a sense of familiarity is evoked. Besides the end of Time to Change, interpretations for declines in other outcomes include the COVID-19 pandemic and economic stress.

A Scoping Review of Military Culture, Military Identity, and Mental Health Outcomes in Military Personnel

INTRODUCTION

The military is a unique cultural institution that significantly influences its members, contributing to the development and transformation of their identities. Despite growing interest in identity research in the military, challenges persist in the conceptualization of military identity, including understanding how it forms, assessing the influence of military culture on identity development, and evaluating the implications for mental health. The primary objective of this scoping review was to map the complexities of military culture's impact on military identity and its effects on mental health.

MATERIALS AND METHODS

A scoping review of the literature was conducted using the Joanna Briggs Institute Scoping Review Methodology. Studies were included if they described military culture, military identity, and mental health, resulting in 65 eligible studies. The extracted data were thematically analyzed to identify how military culture impacts military identity and mental health and well-being.

RESULTS

Multiple identities were evident within the military population, with 2 overarching identities, loyalty and military, overall conferring positive mental health outcomes. Where these identities were hidden or disrupted, poorer mental health outcomes were observed.

CONCLUSIONS

The scoping review conducted in this study challenges the notion of military identity as a singular concept promoting positive mental health outcomes. It highlights its multifaceted nature, revealing that individuals may face identity concealment and disruptions during periods of transition or adjustment, resulting in adverse mental health outcomes. To capture the complexity of military identity, the authors developed the Military Identity Model (MIM). Military leaders, policymakers, and health care professionals are encouraged to recognize the complex nature of military identity and its impact on mental health and well-being. We recommend using the Military Identity Model to explore military identity and adjustment-related difficulties.

In the margins of stigma: health inequalities among Bulgarian Roma in a post-COVID-19 UK

The COVID-19 pandemic had a disproportionate impact on minoritised ethnic groups in the UK, including newly arrived Roma communities. Employing ethnographic and participatory methods, this study illustrates how systemic barriers, including precarious employment and overcrowded housing, coupled with strategies of identity concealment to avoid stigma, severely restrict access to healthcare among Bulgarian Roma communities in the UK. Drawing from fieldwork in Leicester and London, the research reveals how the pandemic amplified the vulnerabilities of Roma populations, directly linking the effects of the pandemic with broader sociopolitical dynamics, including the uncertainties and discrimination associated with Brexit. The findings point to the critical role of community, mutual and familial support networks as essential survival strategies. However, these social networks are also increasingly depleted, revealing the fragility and limits of informal communal resources. The study calls for the development of inclusive health strategies sensitive to the socio-economic and political complexities affecting marginalised communities in the UK and beyond.