Structural determinants of stigma across health and social conditions: a rapid review and conceptual framework to guide future research and intervention

Abstract

Introduction Stigma has been identified as a key determinant of health and health inequities because of its effects on access to health-enabling resources and stress exposure. Though existing reports offer in-depth summaries of the mechanisms through which stigma influences health, a review of evidence on the upstream drivers of stigma across health and social conditions has been missing. The objective of this review is to summarize known structural determinants of stigma experienced across health and social conditions in developed country settings. Methods We conducted a rapid review of the literature. English- and French-language peer-reviewed and grey literature works published after 2008 were identified using MEDLINE, Embase, PsycINFO, Google and Google Scholar. Titles and abstracts were independently screened by two reviewers. Information from relevant publications was extracted, and a thematic analysis of identified determinants was conducted to identify broad domains of structural determinants. A narrative synthesis of study characteristics and identified determinants was conducted. Results Of 657 publications identified, 53 were included. Ten domains of structural determinants of stigma were identified: legal frameworks, welfare policies, economic policies, social and built environments, media and marketing, pedagogical factors, health care policies and practices, biomedical technology, diagnostic frameworks and public health interventions. Each domain is defined and summarized, and a conceptual framework for how the identified domains relate to the stigma process is proposed. Conclusion At least 10 domains of structural factors influence the occurrence of stigma across health and social conditions. These domains can be used to structure policy discussions centred on ways to reduce stigma at the population level.

Integrating time into stigma and health research

“…At a macro level, culture fundamentally shapes stigma processes given that values and priorities shape the ways and extent to which statuses are stigmatized 45 , 46 . Societal-level examples of structural stigma include racial residential segregation 47 , 48 , same-sex marriage bans 49 , 50 , HIV criminalization policies 51 and the war on drugs 52 – 54 . Institutional-level examples include HIV disclosure policies within employment settings 55 , zero-tolerance drug use policies in workplace settings and housing agencies 56 , and the lack of gender-neutral bathrooms and locker rooms in schools 57 .…”

The impact of stigma on HIV testing decisions for gay, bisexual, queer and other men who have sex with men: a qualitative study

“…These forms of stigma-anticipated, interpersonal and intersectional-are all linked to "structural stigma, " or "societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized" [33]. Structural stigma, which may emerge both intentionally or as an unintended consequence of other policies [34], and which has roots in multiple social institutions [35], has been associated with HIV-related behaviors and outcomes for GBQMSM [36][37][38][39][40]. Structural stigma may specifically manifest in "provider-based stigma" [26], or "prejudice and discrimination voiced or exercised, consciously or unconsciously, by occupational groups designated to provide assistance to stigmatized groups" [41].…”

Screening and Referral for Social Determinants of Health: Maternity Patient and Health Care Team Perspectives

“…This collaborative approach may help eliminate stigma, which increases patient stress and restricts their access to health-enabling resources. 26 The National Association of Community Health Centers offers the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) for standardized assessment and to inform process. 27 The PRAPARE toolkit emphasizes empathetic inquiry, including patient-centered support for autonomy/privacy, clear explanations for screening, sharing power by asking about patient priorities, and accounting for stigma.…”