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 |