The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas

Abstract

Stigma is a well-documented barrier to health seeking behavior, engagement in care and adherence to treatment across a range of health conditions globally. In order to halt the stigmatization process and mitigate the harmful consequences of health-related stigma (i.e. stigma associated with health conditions), it is critical to have an explicit theoretical framework to guide intervention development, measurement, research, and policy. Existing stigma frameworks typically focus on one health condition in isolation and often concentrate on the psychological pathways occurring among individuals. This tendency has encouraged a siloed approach to research on health-related stigmas, focusing on individuals, impeding both comparisons across stigmatized conditions and research on innovations to reduce health-related stigma and improve health outcomes. We propose the Health Stigma and Discrimination Framework, which is a global, crosscutting framework based on theory, research, and practice, and demonstrate its application to a range of health conditions, including leprosy, epilepsy, mental health, cancer, HIV, and obesity/overweight. We also discuss how stigma related to race, gender, sexual orientation, class, and occupation intersects with health-related stigmas, and examine how the framework can be used to enhance research, programming, and policy efforts. Research and interventions inspired by a common framework will enable the field to identify similarities and differences in stigma processes across diseases and will amplify our collective ability to respond effectively and at-scale to a major driver of poor health outcomes globally.

How Do We Balance Tensions Between COVID-19 Public Health Responses and Stigma Mitigation? Learning from HIV Research

“…Lesbian, gay, bisexual and transgender (LGBT) persons, sex workers, and people who use drugs, experience criminalization that reduces access to employment, housing, and healthcare, and exacerbates risks for violence and practices that elevate HIV exposure [31][32][33][34]. As an alternative approach, COVID-19 travel bans and quarantine could include anti-stigma and anti-xenophobia public messaging and training of legal authorities [4,35]. Furthermore, UNAIDS recommends that in lieu of criminalization for breaching COVID-19 public health policies, approaches should focus on empowering and strengthening communities to support persons to protect their own and one other's health [8].…”

“…Third, it is necessary to address misinformation and lack of awareness regarding COVID-19-but not sufficient. Stigma mitigation also needs to tackle facilitators such as social inequities [4], including racism and xenophobia. Public health strategies that improve access to COVID-19 testing and employment sick leave benefits have the potential to reduce stigma.…”

“…Fourth, we need to engage persons most affected by COVID-19 in developing stigma mitigation strategies, yet they may experience social and health disparities that present barriers to research participation. Lived experiences of COVID-19 and other intersecting stigmas [4,5,40] can inform contextually specific and stigma-informed public health approaches. For instance, gendered roles as family caregivers and front-line healthcare workers may elevate women's exposure to COVID-19 [41], requiring a genderbased analysis of social and health impacts of public health measures such as quarantine.…”

“…We are called to address the fear of COVID-19 by correcting misinformation [2,3]. While misinformation is indeed a driver of fear and stigma, other underlying facilitators produce stigma [4,5] and need to be considered in stigma mitigation. HIV research and an understanding of the historical construction of illness can be leveraged to mitigate COVID-19 stigma.…”

Development of parallel measures to assess HIV stigma and discrimination among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa

“…attitudes, such as shame of association with and judgement towards PLHIV among CMs and HWs) and manifestations (i.e. internalized stigma – the application of stigma to oneself – and experienced stigma among PLHIV and perceived stigma – a person's understanding of how others may act towards, think, or feel about someone living with HIV ] – among CMs and HWs) of HIV stigma .…”