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Penas P, Uriarte JJ, Alvarez-Gonzalez A, Moreno-Calvete MC, Garay MA, Iraurgi I. The role of personal recovery and internalised stigma on the expression of symptomatology in severe mental disorders: Mediating and moderating effects. J Psychiatr Res 2024; 177:264-270. [PMID: 39053294 DOI: 10.1016/j.jpsychires.2024.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 07/09/2024] [Accepted: 07/14/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE Given the relevance of internalised stigma in people suffering from a mental disorder, in the present study, the possible mediating and moderating role of self-stigma in the relationship between personal recovery and symptomatology has been studied. METHOD 265 participants with severe mental disorder completed the following instruments: ISMI (self-stigma), REE (personal recovery) and HoNOS, CGI, GAF and EuroQol (symptomatology). RESULTS both the mediation and moderation analyses show significant results, which would indicate that internalised stigma has an effect on the relationship between personal recovery and symptomatology. Also, people with lower level of personal recovery and greater self-stigma have greater symptomatology than those who are in more advanced personal recovery processes and have a lower perception of internalised stigma. DISCUSSION the findings of this study suggest that self-stigma has an effect, and the improvement at personal recovery and symptomatology is accentuated when people with a severe mental disorder have a better management of internalised stigma. Therefore, it may be interesting to include this variable in recovery interventions.
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Affiliation(s)
- Patricia Penas
- Department of Psychology, Faculty of Health Sciences, University of Deusto, Bilbao, Bizkaia, Spain.
| | - Jose Juan Uriarte
- Biobizkaia Health Research Institute, Osakidetza Basque Health Service, Bizkaia Mental Health Network, Plaza de Cruces 12, 48903, Barakaldo, Bizkaia, Spain
| | | | - María-Concepción Moreno-Calvete
- Biobizkaia Health Research Institute, Osakidetza Basque Health Service, Bizkaia Mental Health Network, Plaza de Cruces 12, 48903, Barakaldo, Bizkaia, Spain
| | - Maria Asuncion Garay
- Osakidetza Basque Health Service, Bizkaia Mental Health Network, C/ María Díaz de Haro, 58, 48010, Bilbao, Spain
| | - Ioseba Iraurgi
- Department of Psychology, Faculty of Health Sciences, University of Deusto, Bilbao, Bizkaia, Spain
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Zamorano S, Santos-Olmo AB, Sánchez-Iglesias I, Muñoz-Lara I, Muñoz M. The stigma of intellectual disability in Spain: a nationally representative survey. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2024; 68:477-490. [PMID: 38263598 DOI: 10.1111/jir.13122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Stigma towards people with intellectual disability affects various aspects of their lives, including access to employment, housing, health and social care services. Furthermore, this stigma reduces their social opportunities and is even reflected in laws that diminish their autonomy. Due to the practical significance of this issue, the aim of this research is to explore for the first time the social stigma associated with intellectual disability in a representative sample of the Spanish population. METHOD A cross-sectional quantitative descriptive study was conducted, involving a representative sample of the population (N = 2746). The study includes descriptive analyses and hierarchical regressions to examine various dimensions of stigma, such as attitudes, attributions, and intentions of social distance. RESULTS Medium levels of stigma are found regarding attitudes and attributions towards people with intellectual disability, while levels are medium-low concerning the intention of social distance. The most reliable indicators of stigma across its various dimensions encompass attitudes, attributions, and the intention of social distance. Factors that contribute to lower stigma include knowing someone with an intellectual disability, being willing to discuss intellectual disability with an acquaintance who has it and having a progressive political ideology. People with intellectual disability show more negative attributions towards themselves. Living with a person with an intellectual disability is another predictor of more stigmatising attitudes, but less intention of social distance. Results are mixed regarding age, gender, and educational level. CONCLUSION Combating the stigmatisation of people with intellectual disabilities must include comprehensive actions to address attitudes, attributions and behavioural intentions. Public policies, such as national campaigns and programmes, should include contact with and open conversations about intellectual disability, and sensitivity to sociodemographic variables.
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Affiliation(s)
- S Zamorano
- Department of Personality, Assessment and Clinical Psychology, School of Psychology, Complutense University of Madrid, Madrid, Spain
- Chair Against Stigma Grupo 5-Complutense University of Madrid, Madrid, Spain
| | - A B Santos-Olmo
- Department of Personality, Assessment and Clinical Psychology, School of Psychology, Complutense University of Madrid, Madrid, Spain
- Chair Against Stigma Grupo 5-Complutense University of Madrid, Madrid, Spain
| | - I Sánchez-Iglesias
- Department of Psychobiology and Behavioral Sciences Methods, School of Psychology, Complutense University of Madrid, Madrid, Spain
- Chair Against Stigma Grupo 5-Complutense University of Madrid, Madrid, Spain
| | - I Muñoz-Lara
- Chair Against Stigma Grupo 5-Complutense University of Madrid, Madrid, Spain
| | - M Muñoz
- Department of Psychobiology and Behavioral Sciences Methods, School of Psychology, Complutense University of Madrid, Madrid, Spain
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Fernández D, Grandón P, López-Angulo Y, Vladimir-Vielma A, Peñate W, Díaz-Pérez G. Internalized stigma and self-stigma in people diagnosed with a mental disorder. One concept or two? A scoping review. Int J Soc Psychiatry 2023; 69:1869-1881. [PMID: 37646436 DOI: 10.1177/00207640231196749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND In the literature on stigma, authors often use self-stigma or internalized stigma interchangeably to refer to this type of stigma. This results in a lack of conceptual clarity with negative repercussions for measurement and intervention. AIMS To identify how internalized stigma and self-stigma are conceptualized in people diagnosed with a mental disorder and establish similarities and differences between both concepts. METHOD A scoping review was conducted. Thirty-five studies that conceptualized internalized stigma or self-stigma were selected. RESULTS It was identified that the concepts are defined from nine components, and there are more conceptualizations that have points in common than those that consider some component of their own. To gain conceptual clarity, the use of the term internalized stigma is recommended, being a process made up of stages: acceptance of stereotypes and prejudices by people with mental disorders and their subsequent internalization. The latter leads to negative consequences for those affected, which can be understood as the personal impact of this process, which has a crucial socio-cultural component. Lines of research are proposed to provide solidity to studies on this type of stigma. CONCLUSIONS The term internalized stigma should be used when referring to the type of stigma that includes acceptance, internalization and personal impact for the subjects of the stigma. In contrast, self-stigma should be reserved to refer to stigma that is directed toward the 'self' and includes subtypes of stigma.
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Affiliation(s)
- Dany Fernández
- Department of Psychology, Faculty of Social Sciences, Universidad de Concepción, Chile
| | - Pamela Grandón
- Department of Psychology, Faculty of Social Sciences, Universidad de Concepción, Chile
| | - Yaranay López-Angulo
- Department of Psychology, Faculty of Social Sciences, Universidad de Concepción, Chile
| | - Alexis Vladimir-Vielma
- Department of Psychiatry and Mental Health, Faculty of Medicine, Universidad de Concepción, Chile
| | - Wenceslao Peñate
- Department of Clinical Psychology, Psychobiology and Methodology, Faculty of Psychology and Speech Therapy, University of La Laguna -Campus de Guajara-, Tenerife, Spain
| | - Gabriela Díaz-Pérez
- Department of Psychology, Faculty of Social Sciences, Universidad de Concepción, Chile
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González Sanguino C, Santos-Olmo AB, Zamorano S, Sánchez-Iglesias I, Muñoz López M. The stigma of mental health problems: A cross-sectional study in a representative sample of Spain. Int J Soc Psychiatry 2023; 69:1928-1937. [PMID: 37300414 DOI: 10.1177/00207640231180124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Mental health stigma is a relevant phenomenon with implications for the people who suffer from it. Despite its importance, no studies have been carried out in Spain at national level with a representative sample of the population. AIMS The aim of this research is to analyze the stigma associated with MHPs in a representative sample of the Spanish population for the first time. METHOD A cross-sectional quantitative descriptive study was carried out with a representative sample of the population (N = 2746). Descriptive analyses and regressions are carried out on the different dimensions of stigma such as attitude, attribution and intention of social distance. RESULTS Medium levels of stigma are obtained in stigmatizing attitudes and attributions, and medium-low levels in the intention of social distance. The best predictors of stigma in its different dimensions are attitudes, attributions and intention of social distance themselves. Progressive political ideology is related to less stigma in all dimensions. Knowing someone with mental health problems and talking openly about it together with higher education are also relevant protectors. Mixed results are obtained regarding age, gender and help-seeking. CONCLUSION National programs and campaigns focused on attitudes, attributions and behavioral intentions are necessary to reduce the stigma still present in Spanish society.
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Affiliation(s)
- Clara González Sanguino
- Department of Psychology, School of Education and Social Work, University of Valladolid, Spain
- Chair Against Stigma Grupo 5-Complutense University of Madrid, Spain
| | - Ana Belén Santos-Olmo
- Chair Against Stigma Grupo 5-Complutense University of Madrid, Spain
- Department of Personality, Assessment and Clinical Psychology, School of Psychology, Complutense University of Madrid, Spain
| | - Sara Zamorano
- Chair Against Stigma Grupo 5-Complutense University of Madrid, Spain
- Department of Personality, Assessment and Clinical Psychology, School of Psychology, Complutense University of Madrid, Spain
| | - Iván Sánchez-Iglesias
- Chair Against Stigma Grupo 5-Complutense University of Madrid, Spain
- Department of Psychobiology and Behavioral Sciences Methods, School of Psychology, Complutense University of Madrid, Spain
| | - Manuel Muñoz López
- Chair Against Stigma Grupo 5-Complutense University of Madrid, Spain
- Department of Personality, Assessment and Clinical Psychology, School of Psychology, Complutense University of Madrid, Spain
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Ponce-Correa F, Caqueo-Urízar A, Berrios R, Escobar-Soler C. Defining recovery in schizophrenia: A review of outcome studies. Psychiatry Res 2023; 322:115134. [PMID: 36871410 DOI: 10.1016/j.psychres.2023.115134] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
Schizophrenia is a chronic disorder with a heterogenous course and different ways in which recovery is measured or perceived. Recovery in schizophrenia is a complex process that it can be defined either from a clinical perspective focused on sustained symptom and functional remission, or from a patient-focused one, as a self-broadening process aimed at living a meaningful life beyond mental illness. Until now, studies analysed these domains separately, without examining their mutual relations and changes over time. Therefore, this meta-analysis aimed to examine the relationship of global measures of subjective recovery with each of the components of clinical recovery such as symptom severity and functioning, in patients with schizophrenia spectrum disorders. The results showed that the association between different indicators of personal recovery and remission are weak and inverse (dIG+ = -0.18, z = -2.71, p < 0.01), however, this finding is not substantial according to the sensitivity indicators. With respect to functionality and personal recovery, there was a moderate relationship (dIG+ = 0.26, z = 7.894, p < 0.01) with adequate sensitivity indices. In addition, a low consensus exists between subjective measures that are more related to the patient's perspective and clinical measures based on experts and clinician's viewpoint.
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Affiliation(s)
- Felipe Ponce-Correa
- Programa Doctorado en Psicología, Escuela de Psicología y Filosofía, Facultad de Ciencias Sociales y Jurídicas, Universidad de Tarapacá, Avenida 18 de Septiembre N 2222, Casilla 7-D, Arica, Chile
| | | | - Raúl Berrios
- Departamento de administración, Facultad de administración y economía, Universidad de Santiago de Chile, Chile
| | - Carolang Escobar-Soler
- Programa Doctorado en Psicología, Escuela de Psicología y Filosofía, Facultad de Ciencias Sociales y Jurídicas, Universidad de Tarapacá, Avenida 18 de Septiembre N 2222, Casilla 7-D, Arica, Chile
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van Genk C, Roeg D, van Vugt M, van Weeghel J, Van Regenmortel T. Current insights of community mental healthcare for people with severe mental illness: A scoping review. Front Psychiatry 2023; 14:1156235. [PMID: 37143787 PMCID: PMC10151504 DOI: 10.3389/fpsyt.2023.1156235] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/23/2023] [Indexed: 05/06/2023] Open
Abstract
Background For the last four decades, there has been a shift in mental healthcare toward more rehabilitation and following a more humanistic and comprehensive vision on recovery for persons with severe mental illness (SMI). Consequently, many community-based mental healthcare programs and services have been developed internationally. Currently, community mental healthcare is still under development, with a focus on further inclusion of persons with enduring mental health problems. In this review, we aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision on the ingredients of community mental healthcare. Methods We conducted a scoping review by systematically searching four databases, supplemented with the results of Research Rabbit, a hand-search in reference lists and 10 volumes of two leading journals. We included studies on adults with SMI focusing on stimulating independent living, integrated care, recovery, and social inclusion published in English between January 2011 and December 2022 in peer-reviewed journals. Results The search resulted in 56 papers that met the inclusion criteria. Thematic analysis revealed ingredients in 12 areas: multidisciplinary teams; collaboration within and outside the organization; attention to several aspects of health; supporting full citizenship; attention to the recovery of daily life; collaboration with the social network; tailored support; well-trained staff; using digital technologies; housing and living environment; sustainable policies and funding; and reciprocity in relationships. Conclusion We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support.
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Affiliation(s)
- Caroline van Genk
- School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, Netherlands
- *Correspondence: Caroline van Genk,
| | - Diana Roeg
- School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, Netherlands
- Kwintes Housing and Rehabilitation Services, Zeist, Netherlands
| | - Maaike van Vugt
- Trimbos Institute, Dutch Institute of Mental Health and Addiction, Utrecht, Netherlands
- HVO-Querido, Amsterdam, Netherlands
| | - Jaap van Weeghel
- School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, Netherlands
| | - Tine Van Regenmortel
- School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, Netherlands
- Faculty of Social Sciences – HIVA, University of Leuven, Leuven, Belgium
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González-Sanguino C, Muñoz M. Predictors of Implicit and Explicit Internalized Stigma in a Sample With Different Mental Illness Diagnoses. J Nerv Ment Dis 2022; 210:665-671. [PMID: 35344973 DOI: 10.1097/nmd.0000000000001516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT This research aimed to study implicit and explicit internalized stigma and its relationship with other variables in a sample of people with distinct mental illness diagnoses ( N = 160). Descriptive analysis, mean differences, correlations, and stepwise regression models were conducted. Implicit and explicit internalized stigma was found throughout the sample with differences depending on certain sociodemographic variables. Regression models revealed symptomatology, physical environment, personality traits, references to mental illness, and the time taken to seek professional help as predictors of explicit internalized stigma. At the implicit level, only self-esteem was found as a predictor explaining a low percentage of the variance. The results obtained underline the differences between implicit and explicit stigma, suggesting different relevant variables for interventions focused on prevention and internalized stigma reduction.
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Affiliation(s)
- Clara González-Sanguino
- Department of Clinical Psychology, School of Psychology, University Complutense of Madrid, Campus de Somosaguas, Madrid, Spain
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Experiences and impact of living with incontinence associated stigma: A protocol for a systematic review and narrative synthesis of qualitative studies. PLoS One 2022; 17:e0270885. [PMID: 35802573 PMCID: PMC9269749 DOI: 10.1371/journal.pone.0270885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 06/14/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Incontinence is global health and social issue, with urinary incontinence alone affecting over 400 million people. Incontinence can lead to physical harms such as skin damage, but it also commonly causes social and psychological harms, including those associated with stigma. For many people, treatment to cure incontinence does not work or is not suitable and they live with the long-term consequences of incontinence. At the moment, no stigma reduction interventions (increasingly used with other conditions such as mental health problems and HIV) have been developed for people living with incontinence. As a starting point for developing such an intervention, this review will address the questions 1) What are the incontinence (urinary or faecal) associated experiences of stigma of people living with incontinence? 2) What is the impact of incontinence associated stigma on their lives? Methods The reviewers will search Embase, Medline, PsychINFO and the Cumulative Index to Nursing and Allied Health Literature using controlled vocabulary and relevant search terms. Articles assessed to meet inclusion criteria will be included. Once duplicates have been removed, titles and abstracts will be screened and full texts of selected research articles will be reviewed. An adapted Joanna Briggs Institute Data Extraction Form will be used to collect the data and quality will be assessed using the Joanna Briggs Institute checklist for qualitative research appraisal tool. A framework approach (using the Revised Framework for Understanding Non-communicable Disease Related Stigma) will be used to organise, integrate, interpret and summarise findings from included articles. The review will be reported in accordance with the Enhancing Transparency in reporting the synthesis of qualitative research statement. Prospero registration number CRD42021259065. Discussion The systematic review described in this protocol will provide the first in-depth, comprehensive understanding of people’s experiences of the stigma associated with incontinence and the impact that it has on their lives. It will identify broader influences of contextual variables such as age, sex, cause and type of incontinence, socio-economic culture and geographical location. The review aims to provide insights to support the development of incontinence associated stigma reduction interventions.
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González-Sanguino C, Ausín B, Castellanos MÁ, Muñoz M. Mental health in a heterogeneous clinical sample. A cross-sectional study of predictors and gender differences. Heliyon 2022; 8:e09823. [PMID: 35815124 PMCID: PMC9260627 DOI: 10.1016/j.heliyon.2022.e09823] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/27/2022] [Accepted: 06/24/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Women have been shown to be a vulnerable group in relation to mental health problems over time. Despite this, gender-focused studies are uncommon. The aim of this research is to study mental health in a sample of people with mental health problems and to analyze the differences and predictors focusing on gender. Methods A cross-sectional study is conducted in a heterogeneous clinical sample in terms of mental health problems (N = 160). Interviews with hetero-reported standardized questionnaires to collect the data are conducted. Descriptive analyses, mean difference and a regression analysis on mental health are carried out taking into account different sociodemographic, clinical and psychosocial variables. Results Women in the study present worse levels of mental health and subjective severity of the disorder. The main predictors of mental health are being female, followed by severity, shorter time with the diagnosis and internalized stigma. Conclusion Being female is the most robust predictor of worse mental health and symptomatology. Recommendations according to the results found proposing a gender perspective are suggested.
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Affiliation(s)
- Clara González-Sanguino
- Clinical Psychology Department, School of Education and Social Work, University of Valladolid, Extraordinary Chair Against Stigma UCM-Group 5, Spain
- Corresponding author.
| | - Berta Ausín
- Clinical Psychology Department, School of Psychology, University Complutense of Madrid, Extraordinary Chair Against Stigma UCM-group 5, Spain
| | - Miguel Ángel Castellanos
- Department of Psychobiology and Methodology in Behavioral Science, School of Psychology, University Complutense of Madrid, Spain
| | - Manuel Muñoz
- Clinical Psychology Department, School of Psychology, University Complutense of Madrid, Extraordinary Chair Against Stigma UCM-group 5, Spain
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González-Sanguino C, Castellanos MÁ, González-Domínguez S, Muñoz M. Talking about mental illness, professional help, self-esteem and health. A structural equation model of implicit and explicit internalized stigma. CURRENT PSYCHOLOGY 2021. [DOI: 10.1007/s12144-021-01930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chen S, Lu Q, Bai J, Deng C, Wang Y, Zhao Y. Global publications on stigma between 1998-2018: A bibliometric analysis. J Affect Disord 2020; 274:363-371. [PMID: 32469828 DOI: 10.1016/j.jad.2020.05.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To describe the development process and structural relationships of scientific achievements on stigma over the past two decades and to provide insights for researchers and policy makers to drive policy decisions and identify future research needs. METHODS Quantitative analysis of publications was directly interpreted and graphed through Web of Science and ORIGIN 2017. The co-occurrence and collaboration analysis between authors, countries and keywords were conducted through VOSviewer. Keyword burst was detected through CiteSpace. RESULTS The retrieved 2,799 publications showed a trend of increasing annual publications between 1998 and 2018. The United States made the greatest contribution to global publications regarding stigma. Four keyword clusters indicating research hotspot were identified through the default clustering method in VOSviewer. Meta-analysis and internalized stigma were detected as keyword bursts in recent years. CONCLUSIONS The growth trend of publications indicated increased research interest in stigma, especially common stigma types, including HIV stigma and obesity stigma. Future research should focus on other types of stigma and should include more elaborate intervention programs, mechanism exploration, and research on internalized stigma. Scientific research on stigma requires an extensive collaborative endeavor, both domestically and internationally, among diverse researchers, institutions, and countries.
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Affiliation(s)
- Shixiang Chen
- School of Nursing, Tianjin Medical University, Tianjin, 300070, China.
| | - Qi Lu
- School of Nursing, Tianjin Medical University, Tianjin, 300070, China.
| | - Jinbing Bai
- NHW School of Nursing, EMORY UNIVERSITY, 1520 Clifton Road, Atlanta, USA.
| | - Cuiyu Deng
- Oncology Department, The Second Hospital of Tianjin Medical University, Tianjin, China.
| | - Yaogang Wang
- School of Public Health, Tianjin Medical University, Tianjin, 300070, China.
| | - Yue Zhao
- School of Nursing, Tianjin Medical University, Tianjin, 300070, China.
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