The Multilevel Relationships of HIV‐Related Stigma to Child and Caregiver Mental Health among HIV‐Affected Households in South Africa

Abstract

HIV/AIDS‐related (HAR) stigma is still a prevalent problem in Sub‐Saharan Africa, and has been found to be related to mental health of HIV‐positive individuals. However, no studies in the Sub‐Saharan African context have yet examined the relationship between HAR stigma and mental health among HIV‐negative, HIV‐affected adults and families; nor have any studies in this context yet examined stigma as an ecological construct predicting mental health outcomes through supra‐individual (setting level) and individual levels of influence. Multilevel modeling was used to examine multilevel, ecological relationships between HAR stigma and mental health among child and caregiver pairs from a systematic, community‐representative sample of 508 HIV‐affected households nested within 24 communities in KwaZulu‐Natal, South Africa. Two distinct dimensions of HAR stigma were measured: individual stigmatizing attitudes, and perceptions of community normative stigma. Findings suggest that individual‐level HAR stigma significantly predicts individual mental health (depression and anxiety) among HIV‐affected adults; and that community‐level HAR stigma significantly predicts both individual‐level mental health outcomes (anxiety) among HIV‐affected adults, and mental health outcomes (PTSD and externalizing behavior scores) among HIV‐affected children. Differentiated patterns of relationships were found using the two different stigma measures. These findings of unique relationships identified when utilizing two conceptually distinct stigma measures, at two levels of analysis (individual and community) suggest that HAR stigma in this context should be conceptualized as a multilevel, multidimensional construct. These findings have important implications both for mental health interventions and for interventions to reduce HAR stigma in this context.

Stigma by Association, Parenting Stress, and the Mental Health of Caregivers of Adolescents Living With HIV in Uganda

“…Given the lack of stigma reduction interventions and programs to provide coping resources for families, and specifically caregivers of children and ALHIV, it is possible that caregivers end up suffering in silenced—negatively impacting their mental health functioning. These findings are consistent with other studies in SSA, including in Uganda [ 24 ] and South Africa [ 25 , 34 ] that have investigated HIV-related stigma and caregiver’s mental health. Similar mental health outcomes have been documented among caregivers of children orphaned by HIV/AIDS in Uganda [ 35 , 36 ].…”

“…In sub-Saharan Africa (SSA), however, the majority of studies have explored caregivers’ experiences with PLHIV [ 22 , 23 ]. Very few studies have investigated how HIV-related stigma impacts caregivers’ mental health [ 24 , 25 ]. Yet, caregiver mental health directly impacts the well-being of children under their care, quality of care provided, and overall family functioning [ 26 , 27 ].…”

The stigma system: How sociopolitical domination, scapegoating, and stigma shape public health

“…Research agendas to understand stigma systems should embrace a wealth of different methodologies, disciplines, and, indeed, ontological frameworks. On the one hand, the issues raised in this paper can be addressed using standard positivistic, quantitative multilevel statistical models in which stigma in different geographic units are studied (Williams et al, 2019(Williams et al, , 2020. Longitudinal models that assess variation over both place and time could capture potential causal pathways.…”

“…Corrigan, Pescosolido, Martin (Corrigan et al, 2004;Pescosolido & Martin, 2015), Link, Phelan, Hatzenbuehler, and their collaborators have written a number of articles on structural stigma, 1 how stigma can benefit powerful groups, and the moral/cultural dimensions of stigma (Hatzenbuehler et al, 2013;Hatzenbuehler, 2016;Link & Phelan, 2001;Link & Phelan, 2014;Phelan et al, 2008;Yang et al, 2007;Yang et al, 2014). HIV/AIDS researchers have considered stigma in its interlocking social and personal dimensions, including setting-level variation in stigmatizing ideologies and intrapersonal normative processes (Williams et al, 2019(Williams et al, , 2020, and the ways in which such prevailing ideologies are used by the powerful to maintain inequality and, to some degree, how the disempowered resist this (Lichtenstein, 2014;Parker & Aggleton, 2003). The literature on structural violence has also covered these themes (Farmer et al, 2011;Farmer, 2010;Yang et al, 2014).…”

“…This paper presents a model of what we call the "stigma system" and its interacting components of stigma, the social processes that create, strengthen, or maintain stigma, and the sociopolitical forces that resist, weaken or eliminate stigma. This view of the stigma system as a multilevel system in which individual, organizational, ideological, and macrosocial conflicts interact in a dialectic, as pictured in Figure 1, may help public health and other fields move beyond an individualized model that sees solutions primarily in terms of helping clients or patients cope with the ill effects of stigma on themselves-which might sometimes reduce pressures for social change in the process (Williams et al, 2019(Williams et al, , 2020.…”