Implementation science and stigma reduction interventions in low- and middle-income countries: a systematic review

Abstract

Background Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions. Methods PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR). Results A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven. Conclusion Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide. Electronic supplementary material The online version of this article (10.1186/s12916-018-1237-x) contains supplementary material, which is available to authorized users.

Non-Communicable Diseases-Related Stigma: A Mixed-Methods Systematic Review

“…However, the review also found that they can play a very important part in providing social support to those affected, thereby helping in the mitigation of stigma. This ambivalent and dual nature of family, friends, and healthcare professionals has been noted by previous studies on HIV [ 73 , 74 , 75 , 76 ], depression [ 77 ], and leprosy [ 78 , 79 ] that have largely attributed it to the individual’s relevant knowledge, familiarity, and experience in regard to the disease—or lack thereof [ 73 , 74 , 75 , 77 ]. Similarly, we also identified the role of media as a “double-edged sword” as it often played a part as a source of stigma through negative portrayal and stereotyping of those affected [ 9 , 59 , 65 ], but sometimes also as a supportive agency in combating health-related stigma in society by raising awareness [ 80 , 81 ].…”

Qualitative Exploration of Experiences and Consequences of Health-related Stigma among Indonesians with HIV, Leprosy, Schizophrenia and Diabetes

“…2,15,59 Furthermore, they undermine the public health response and cause a negative impact on their overall effectiveness. 18,19,21 The findings of this study have several implications for public health research and practice in Indonesia. First, the prospects of stigma reduction response at different levels of the society are clear.…”

“…19,20 Low-and middle-income countries (LMICs) are known to be disproportionately affected by healthrelated stigma because of the existence of subjugating social norms, lack of health awareness, and inequitable access to health services that contribute to stigma and its negative effects. 21,22 However, much of the burden of health-related stigma in LMICs still remains hidden and unaddressed because of the lack of wider recognition in health policies and practices. 21 As the world's fourth-most populous developing nation currently in epidemiological transition with relatively high prevalence and distribution of noncommunicable and communicable diseases, Indonesia is particularly vulnerable to the burden of stigma compared with other Southeast Asian countries.…”

“…21,22 However, much of the burden of health-related stigma in LMICs still remains hidden and unaddressed because of the lack of wider recognition in health policies and practices. 21 As the world's fourth-most populous developing nation currently in epidemiological transition with relatively high prevalence and distribution of noncommunicable and communicable diseases, Indonesia is particularly vulnerable to the burden of stigma compared with other Southeast Asian countries. 23,24 It has the highest prevalence of HIV in the Southeast Asian region, 25 and leprosy has the thirdhighest prevalence in the world.…”

Celebrating the struggle against homophobia, transphobia and biphobia as central to ending HIV transmission by 2030

“…Sexual orientation and gender identity change efforts have been shown to cause significant harm, especially for LGBTI youth, and should not be sanctioned by any accrediting body or government [13,14]. Anti‐stigma interventions using participatory theatre, professional training and other modalities have been effective in reducing interpersonal stigma and healthcare stigma that underpin experiences of LGBTI violence [15‐17]. Ensuring that healthcare workers are trained to provide welcoming and competent care for LGBT people is key to engaging key populations effectively in HIV prevention and care and to promoting an effective human rights‐based response to the COVID‐19 pandemic.…”