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Table 5 Research on substance use and stigma in LMIC, 2008–2017

From: A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries

Study (First author, year [ref.]) Location Sampling characteristics Sample size Study design Type of stigma assessed Description of stigma association (strength, significance) Significant mediators/moderators
Brittain, 2017 [208] South Africa HIV-infected women receiving antenatal care in Cape Town primary care clinic were enrolled when entering PMTCT services 580 Cross-sectional HIV stigma (non-specified) Higher HIV-related stigma was associated with reduced odds of alcohol use (p < 0.01) None
Budhwani, 2017 [209] Dominican Republic Transgender women who did and did not report recent drug use were recruited and interviewed using a snowball sampling approach 287 Cross-sectional Experienced stigma Higher stigma scale score associated with greater odds of recent cocaine use (p < 0.01) but not other drug use None
Capezza, 2012 [144] Chile Adults in 10 primary care centers were recruited using a time-limited sampling from a clinical population 2839 Cross-sectional Perceived stigma/discrimination Past 6-month discrimination (based on race, sex, age, appearance, disability, sexual orientation, economic status, political affiliation, and/or religion) was associated with significantly higher odds of past 6-month hazardous drinking (p = 0.001) and any illegal drug use (p < 0.001) None
Coelho, 2015 [145] Brazil Undergraduate students were selected using a two-stage sampling procedure at a university 1264 Cross-sectional Experienced stigma/discrimination There was no association between lifetime discrimination and recent alcohol use in the overall sample; however, moderator analyses indicated that last-year students with discrimination had higher odds of alcohol-related problems than first-year students who did not experience discrimination (p < 0.05) and those who experienced two or more types of discrimination had higher odds of alcohol-related problems compared to those who experienced no discrimination or discrimination of one type only Mod: Year of study in university (last year students who experienced discrimination had higher odds of alcohol-related problems compared to first year students who did not experience discrimination)
Culbert, 2015 [210] Indonesia Stratified random sample of prisoners who were HIV-infected in two prisons in Jakarta 102 Mixed methods HIV stigma scale (stereotypes, disclosure concerns, self-acceptance, social relationships) Significantly higher stigma scale scores were reported among participants who were incarcerated for a drug offense, had sought treatment for substance use problems, and those who reported opioid withdrawal symptoms during incarceration None
Deryabina, 2017 [132] Kyrgyzstan Persons with injection drug use were recruited from needle exchange and syringe programs (NSP) and from local NGOs; NSP staff were also interviewed 123 Qualitative Not specified ‘Fear to be a known drug user’ was commonly cited as barrier to accessing NSP services; concerns about disclosure of using injection drugs were cited including fears of losing employment, social stigma, rejection from family/friends, fear of police, and being treated poorly by healthcare professionals None
Du, 2012 [127] China Persons with injection drug use were recruited from a computerized database and were asked to complete a survey; clients in a methadone maintenance program were invited to participate in focus groups; clinic staff also participated in focus groups 610 Mixed methods Not specified Stigma/discrimination was a barrier for persons with injection drug use getting tested for HIV; participants identified stigma both towards their drug use and HIV status; some participants also expressed fear of police and being placed in compulsory drug treatment None
Fan, 2016 [211] China MSM were recruited from local community-based organizations and through snowball sampling 391 Cross-sectional HIV-related stigma scale (domains: shame, blame, social isolation, discrimination, equity) MSM who reported any alcohol use also reported significantly higher levels of stigma than non-drinkers; stigma scale scores were highest among those with heavy alcohol use None
Go, 2016 [212] Vietnam PWID who were newly diagnosed with HIV were enrolled from a parent RCT; data were collected at baseline and 1 month later (pre-intervention) 336 Cohort HIV and drug stigma (non-specified) Neither HIV nor drug stigma were associated with HIV status disclosure in adjusted models None
Goldstone, 2017 [213] South Africa Mental healthcare workers who worked with persons with substance use disorders and suicidal ideation were interviewed 18 Qualitative Not specified Stigma related to substance use, mental illness, and suicide was identified as a barrier to suicide prevention among persons who have substance use disorders None
Greene, 2013 [214] China Clinic-based sample of current or former PWID who were HIV-infected were recruited; caregivers (outside of clinical care) of patients also interviewed 96 Cross-sectional Patient-level perceived HIV-related stigma; caregiver-level stigma towards HIV Patient-perceived stigma was associated with poor mental health and a lack of social support among caregivers; caregivers lack of social support was attributable to their own HIV stigma; higher caregiver stigma was also associated with less caregiver self-efficacy None
Ha, 2015 [147] Vietnam Respondent-driven sampling to recruit MSM 451 Cross-sectional Experienced, perceived, and internalized homosexuality-related stigma Experienced and perceived stigma were both associated with depression, which in turn predicted drug and alcohol use, and, ultimately, sexual risk behaviors Med: Relationship of stigma and sexual risk behaviors was mediated by depression and alcohol/substance use
Hayes-Larson, 2017 [141] Lesotho Baseline data from a mixed methods cluster randomized trial of HIV-TB co-infected patients 371 Cross-sectional Not specified 25% of the sample reported hazardous/harmful alcohol use; greater external HIV and TB stigma associated with hazardous/harmful alcohol use None
Heath, 2016 [215] Thailand Peer-based recruitment used to recruit participants who had injection drug use in the past 6 months 437 Cross-sectional Experienced stigma Experienced stigma, including verbal abuse about their drug use, being discouraged from participating in family activities, and refused medical care by healthcare workers, were associated with avoiding accessing health services None
Howard, 2017 [124] South Africa Street-outreach methods were used to recruit women who use substances for FGDs; primary healthcare and rehab staff were also recruited for FGDs 60 Qualitative Not specified Stigma was identified as a barrier to accessing primary care and substance use treatment services for women who use substances None
Ibragimov, 2017 [138] Tajikistan Purposive sampling used in pharmacies to recruit pharmacists and pharmacy students for in-depth interviews 28 Qualitative Not specified Themes related to stigma among pharmacists and pharmacy students towards PWID included having negative emotions, connotations, and stereotypes of PWID; examples included support for isolation of PWID and forced treatment, and refusal to provide syringe access and other resources None
James, 2012 [139] Nigeria Medical students who had completed a clerkship in Psychiatry and recent medical graduates were interviewed 254 Cross-sectional Attitudes Towards Mental Illness Questionnaire Medical students and recent medical graduates displayed significantly stigmatizing attitudes towards persons who use alcohol and cannabis None
Jamshidimanesh, 2016 [125] Iran Women with substance abuse were recruited from local drop-in center clinics 32 Qualitative Not specified Stigma towards addiction was identified as a barrier to healthcare treatment None
Johannson, 2017 [216] Estonia Respondent-driven sampling used to recruit PWID who were HIV infected 312 Cross-sectional Internalized HIV and drug stigma Internalized HIV and drug stigma were high; internal drug use stigma was negatively associated with disclosure of drug use to family members (non-parents) and healthcare workers; internalized HIV stigma was positively associated with disclosure to healthcare workers; neither HIV nor drug stigma were associated with disclosure of use to sexual partners, close friends, or parents Mod: Authors investigated interaction of HIV and drug stigma; interaction effects on disclosure were non-significant
Kekwaletswe, 2014 [131] South Africa Purposive sample of HIV patients in ART clinics 304 Cross-sectional Experienced and anticipated HIV stigma Among those who reported using alcohol, higher levels of HIV stigma were associated with skipping ART doses None
Kerrigan, 2017 [143] Brazil Proportional random sampling of persons with HIV in six public health facilities 900 Cross-sectional Internalized and experienced HIV stigma (Berger scale) History of drug use was associated with higher levels of stigma/discrimination None
Khuat, 2015 [217] Vietnam Respondent-driven sampling of women with injection drug use 403 Cross-sectional Gender-based stigma Women with injection drug use reported substantial gender-related stigma None
Krawczyk, 2015 [218] Brazil Purposive sample recruited by community leaders of adults who used crack 38 Qualitative Not specified Almost all participants reported significant stigmatization due to their crack use, including being labelled as ‘thieves’ or ‘sick’; many also reported discrimination in health services None
Lan, 2017 [126] Vietnam Baseline data from an RCT; participants were persons with injection drug use from 60 randomly selected commune health centers 900 Cross-sectional Perceived and internalized drug-related stigma Drug-related stigma was associated with reduced overall access to general healthcare but was not associated with MMT or needle exchange program access None
Lembke, 2015 [219] China Persons who used heroin and were seeking treatment were recruited from a local hospital for in-depth interviews 9 Qualitative Not specified All participants reported intense stigma towards persons who use drugs, including social exclusion; participants also reported confidential, anonymous treatment as a facilitator for accessing services None
Liao, 2014 [220] China Mixed recruitment methods (community outreach, snowball sampling) was used to recruit MSM 1230 Cross-sectional HIV-related stigma scale (domains: shame, blame, social isolation, discrimination, equity) HIV-related stigma was common among this MSM sample and was associated with increased alcohol use None
Lim, 2013 [134] Vietnam Baseline data from RCT; PWID recruited from active recruiters and peer referral; community members recruited through systematic sampling 3023 Cross-sectional HIV-related stigma scale (domains: shame, blame, social isolation, discrimination, equity) Drug-related stigma (internalized, perceived, experienced) among PWID; perceptions of PWID among community members Higher education inequality was associated with more HIV-related stigma among PWID and among community members; lower individual education associated with greater HIV and drug stigma among both PWID and community members; individual level education negated the effect of community-level education inequality; part-time employed PWID reported more perceived and experienced stigma than full-time employed PWID Mod: Cross-level interactions of community and individual predictors that community SES did not vary by individual level SES
Lozano-Verduzco, 2016 [221] Mexico Women were recruited from an addiction treatment clinic and through snowball sampling for in-depth interviews 13 Qualitative Not specified Women reported experiences of gender-based stigma and stigma related to their substance use; they reported that women who use substances experience significantly more stigma than men
Psychiatric comorbidities lead to additional stigmatization; these combined stigmas reduce treatment seeking
None
Luo, 2014 [222] China Random sample of households in two communities was conducted 848 Cross-sectional Community members were asked about labelling, stereotyping, and social distancing in response to vignettes about drug users and non-drug users Vast majority of participants labelled persons with drug dependence as ‘addicts’ as opposed to other options of ‘normal’ or ‘patient’; persons with drug dependence were stereotyped negatively compared to persons without drug dependence
Participants also expressed desire to have significant social distance from persons with drug dependence and a low willingness to interact with them
None
Mattoo, 2015 [223] India Purposive sample of persons with alcohol and opioid dependence and one of their family members, recruited from a drug treatment center 200 (100 patient/family member dyads) Cross-sectional Perceived drug-related stigma Perceived stigma about persons who use substances was highly concordant between persons with alcohol and opioid dependence and their family members None
Mimiaga, 2010 [130] Ukraine Participants who were receiving HIV treatment at a local clinic and had been infected through injection drug use were recruited for FGDs 16 Qualitative Not specified HIV-related stigma was mentioned by all participants as a barrier to treatment adherence; participants feared that disclosing HIV status would identify them as a person who injects drugs; others reported fear of rejection from family if they disclosed their HIV status; discrimination by healthcare providers was also mentioned as a source of HIV-related stigma None
Moomal, 2009 [146] South Africa Representative sample of South African adults from the South African Stress and Health Survey 4351 Cross-sectional Acute and chronic discrimination both related and unrelated to race Acute racial and non-racial discrimination and chronic non-racial discrimination were associated with increased risk for substance use disorders None
Mora-Rios, 2017 [133] Mexico Persons who use drugs and their family members were recruited through psychiatric care facilities; healthcare personnel were also recruited 35 Qualitative Not specified Persons who used alcohol and drugs, their family members, and healthcare workers frequently reported family, healthcare personnel, and persons in the street/neighbors as sources of stigma; all persons who used substances reported being an object of social stigma, which was also viewed as a barrier to recovery None
Myers, 2013 [224] South Africa Participants were South Africans who self-identified as Black African or colored who had alcohol or other drug use problems and had sought treatment (cases) or had not sought treatment (controls); cases were recruited from treatment facilities; controls were recruited from the community 434 Case–control Stigma consciousness scale (perceived drug-related stigma) There was no association between stigma and alcohol or other drug service use among Black African participants; among colored participants, perceived stigma was associated with increased odds of service use None
Otiashvili, 2013 [225] Georgia Women who used injection drugs were recruited through peer-to-peer and peer-to-professional word-of-mouth for in-depth interviews; purposive sampling was used to recruit healthcare staff 89 Qualitative Not specified Participants described intense stigmatization that was a major barrier to treatment seeking and access; stigma was also thought to be a more significant barrier to treatment access among women than among men who use substances None
Papas, 2017 [142] Kenya Baseline data from RCT participants who were HIV-infected outpatients and used alcohol 614 Cross-sectional HIV-related stigma (public attitudes towards HIV, ostracization, discrimination, personal life disruption) Women reported higher levels of HIV-related stigma than men; stigma was associated with an increased odds of experiencing sexual or physical violence among both men and women None
Peacock, 2015 [226] El Salvador Respondent-driven sample of MSM and transgender women 670 Cross-sectional Internalized homonegativity scale Binge drinking prevalence was high in the overall sample; higher levels of internalized homonegativity were associated with increased binge drinking None
Rathod, 2015 [227] India Community sample recruited through cluster sampling design in a rural district 3220 Cross-sectional Internalized stigma of mental illness Stigmatizing belief of shame was commonly reported among those with alcohol use disorders, which may have resulted in a low rate of treatment seeking None
Ronzani, 2009 [140] Brazil Primary healthcare professionals were recruited to participate 609 Cross-sectional Attitudes towards use of alcohol and other drugs Alcohol, tobacco, marijuana, and cocaine use were negatively judged behaviors by healthcare professionals relative to other conditions (e.g., mental health problems, HIV); persons with alcohol, marijuana, and cocaine problems suffered the highest rate of service refusal None
Sarkar, 2017 [135] India Persons with alcohol or opioid use disorders were recruited from a treatment facility 201 Cross-sectional Internalized stigma of mental illness There were high levels of internalized stigma across study participants; persons with alcohol and opioid use disorder with severe stigma had significantly lower physical, social, psychological, and environmental quality of life scores than those with mild-to-moderate stigma None
Schensul, 2017 [129] India Men living with HIV were recruited from ART treatment centers 361 Mixed methods Experienced stigma Men who drank alcohol at higher levels had a greater risk of non-ART adherence; men also reported skipping ART doses when drinking with friends due to fear of HIV status disclosure None
Sharma, 2017 [228] India Purposive sampling to recruit women with non-injection drug use; women who had injection drug use were also recruited from a parent prospective cohort study 48 Qualitative Not specified Stigma from healthcare providers was reported as a significant barrier to accessing services None
Spooner, 2015 [229] Indonesia Outreach workers recruited women who had injection drug use 19 Qualitative Not specified Women who used injection drugs felt significant stigma and shame; they reported social exclusion, isolation from society and from treatment options; they also reported sharing of needles with small groups of trusted friends None
Ti, 2013 [128] Thailand Peer-based outreach and word-of-mouth recruiting used to recruit persons who injected drugs; sample restricted to those HIV-negative or unknown HIV serostatus 350 Cross-sectional Experienced stigma Having been refused healthcare services was associated with avoiding getting an HIV test None
Van Nguyen, 2017 [137] Vietnam Patients taking MMT at one of two MMT sites were recruited 241 Cross-sectional HIV and drug-related stigma (blame/judgment, shame, discrimination, disclosure, others’ fear of HIV transmission) Almost all participants reported experiencing blame/judgment, discrimination, and shame Unemployment was associated with discrimination; blame, judgment, and shame were associated with anxiety and depression None
Yang, 2015 [136] China Males with drug dependence who were formerly abstinent were purposively recruited from a compulsory drug treatment center 18 Qualitative Not specified Participants reported that, even during periods of abstinence, they perceived stigma from the community, including family and healthcare service providers; participants also reported feelings of shame; many reported social exclusion and difficulty finding employment Participants reported that stigma resulted in low treatment seeking and may have contributed to relapse None
Zhang, 2016 [32] China Persons living with HIV were randomly selected for participation from a parent study 2987 Cross-sectional Perceived, experienced, and internalized HIV stigma (Berger scale) In overall sample, perceived stigma was associated with drug use; among those with higher incomes, internalized stigma was associated with drug use and experienced stigma was associated with alcohol use
Perceived stigma was associated with drug use in rural areas
Mod: Relationship between stigma and drug use modified by income; odds of alcohol and drug use were highest among those with both higher levels of stigma and higher income; also modified by place of residence
Those with higher levels of perceived stigma living in rural areas had increased odds of drug use compared to urban areas
  1. ART antiretroviral therapy, FGD focus group discussion, MMT methadone maintenance therapy, MSM men who have sex with men, NSP needle and syringe programs, PMTCT prevention of mother-to-child transmission, PWID persons with injection drug use, RCT randomized controlled trial, SES socioeconomic status