Skip to main content

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