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

Abstract

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

Theories for interventions to reduce physical and verbal abuse: A mixed methods review of the health and social care literature to inform future maternity care

“…The theories and operational factors discussed in the included papers in both phases of the review covered all levels of the socio-ecological model, and are similar to those identified in other papers in the Series of which this review is a part [ 4 , 5 ]. The theories identified operated at the individual level (e.g.…”

“…We suggest that one way of understanding and then addressing the issue of verbal and physical mistreatment in specific maternity care systems in future is to work with local stakeholders (staff, managers, community, service users, policy makers) to establish the extent to which the ‘simple rules’, contextual drivers and theories of discrimination and stereotyping revealed in this paper, and in the other papers in the Series [ 4 , 5 ] explain verbal and physical abuse locally. This mapping exercise should be done at every level of the local socio-ecological system, using the proposed socio-ecological-behavioural approach, alongside an existing compatible model, such as the Behavioural Change Wheel [ 274 ].…”

A critical interpretive synthesis of power and mistreatment of women in maternity care

“…These trainings examine multiple levels of the social ecological model, such as training providers to recognize health care institutions as structures that influence power dynamics [147], or training health workers to be advocates for policy change, such as to alter policies that criminalize or stigmatize certain patient groups [143][144][145]. Relatedly, clinician interventions utilizing reproductive justice frameworks train and empower clinicians to intervene during instances of mistreatment or to serve as broader societal advocates for reproductive justice [74,[148][149][150]. Reproductive justice, as envisioned by Black feminist advocates in the US, includes the key tenets of rejecting population control/eugenics; centering marginalized groups; recognizing intersecting forms of oppression; linking theory, strategy, and practice; and commitment to shifting power [148].…”

“…power to). (A companion paper PLOS GLOBAL PUBLIC HEALTH in this Series presents a mixed-methods systematic review of strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings [149]) Moreover, stigma and discrimination are driven by a variety of factors, including state geo-and ethno-political objectives, harmful community norms, and provider prejudices regarding fitness for motherhood. In contexts where pressure to achieve objectives is high and resources are scarce, providers may feel that differential treatment of patients is unavoidable and thus mete out worse treatment to lower status patients.…”

Antibias Efforts in United States Maternity Care: A Scoping Review of the Publicly Funded Health Equity Intervention Pipeline

“…2,22 Piloting interventions with these types of components in maternal health care is necessary to develop evidence-based guidelines. However, a recent international systematic review on interventions to reduce stigma and discrimination in sexual and reproductive health care settings 24 identified only 1 evaluated intervention designed to reduce bias among United States-based maternal health care providers. 25 In light of the increase in public and governmental support for antibias and antiracism interventions, 4,20,21 we sought to investigate whether recent national publicfunding reflects this heightened priority.…”