Table 1 Illustrative examples of how the Health Stigma and Discrimination Framework can be applied to different health conditions
Health condition | Driversa | Facilitatorsa | Intersecting stigmasa | Manifestationsa (experiences and practices) | Outcomes (affected populations) | Outcomes (organizations and institutions) | Impacts |
|---|---|---|---|---|---|---|---|
Leprosy | Fear of contagion, social exclusion, and disfigurement; Beliefs that persons affected by leprosy must have sinned, are ritually impure (Hinduism); have broken taboos (e.g. sexual relations during a woman’s period); belief that leprosy is hereditary | Persons affected by leprosy often have a low SES, have low or no education, low or no awareness of human rights, and are not used to speaking up for themselves | Gender, ethnic background (e.g. caste) in several societies | Experiences: The identity of persons affected is spoiled – they lose status and reputation; this also affects family members They face restrictions in social participation, e.g. problems to find or keep work, problems in accessing education, diminished opportunities for marriage or problems in marriage, problems with friendships, problems in using public facilities, and concealment Practices: Negative attitudes, stereotypes and prejudice towards people with leprosy persist in communities | Concealment may cause delay in treatment, poor treatment adherence, and poor treatment outcomes | Working in leprosy services is unpopular and thus good, well-qualified staff is difficult to find; patients still sent to leprosy hospitals, even for non-leprosy-related conditions, which can lead to poor quality of health services and high turnover of staff | Reduced mental wellbeing, depression and anxiety, (attempted) suicide, aggravated poverty due to loss of income, increased severity of disability, reduced quality of life, prolonged transmission of bacilli in community |
Epilepsy | Fears about productivity and longevity (ability to contribute to society) | Religion, supernatural beliefs | Other health conditions (e.g. cerebral palsy), gender, race | Experiences: Employment discrimination, internalization of stigma Practices: Social rejection and distancing, stereotypes about people with epilepsy and their ability to be productive members of society | Treatment self-efficacy, medication adherence | Employment and driving restrictions | Quality of life |
Mental health | Beliefs that persons with mental health issues are dangerous (unpredictable, violent), responsible for their issue, cannot be controlled or recover, should be ashamed | Persons with mental health issues viewed as incompetent (cannot work or live independently) or may not be empowered to claim their rights | Race, gender, sexual orientation | Experiences: Internalized stigma, perceived stigma, experienced stigma, discrimination, secondary stigma Practices: Persistent negative public attitudes, opinions and intentions, for example, regarding having a person with mental health issues provide childcare, teach children, marry into the family, attempt self-harm, or hold authority positions | Delays people from accessing, engaging in, and completing mental health treatment | Enactment of protective laws and policies at the national and state-levels and in workplaces, including health facilities | Lowered self-efficacy and self-esteem, compromised engagement in employment and independent living, depression, poor quality of life |
Cancer | Fear of infection, perceptions of disfigurement, attributions of blame for contracting the disease, guilt, shame and blame | Religion and culture, perceived responsibility and controllability of cause | Smoker, obesity | Experiences: Internalization of stigma Practices: Social rejection, avoidance, distancing | Delayed screening and treatment seeking, disruption of personal relationships, financial burden | Employment and driving restrictions, health insurance coverage | Quality of life, motivation and efforts to conceal condition, morbidity and mortality |
HIV | Fear of infection, fear of economic ramifications due to chronic nature of health condition, fear of poor productivity and longevity, social norm enforcement | Laws criminalizing HIV infection, unenforced protective laws regarding key populations (i.e. men who have sex with men, sex workers, injection drug users, etc.), the availability of universal protection supplies in health facilities, prevailing norms about populations most vulnerable to HIV infection | Sexual orientation, occupation (i.e. sex work), race, substance use | Experiences: Social rejection and distancing, gossip, poor healthcare, internalization of stigma, secondary stigma for family and healthcare workers providing care to people living with HIV Practices: Discriminatory attitudes about people living with HIV, stereotypes and prejudice | HIV risk behaviors, HIV testing, engagement and retention in care, initiation and adherence to medication | HIV-related laws and policies (i.e. criminalization of transmission, travel restrictions), workplace policies, pre- and in-service training curricula for healthcare providers, and other duty bearers | HIV incidence, morbidity and mortality, social inclusion, quality of life |
Obesity and body weight | Beliefs that body weight is controllable and people are responsible for their obesity or overweight; Association with laziness and irresponsibility, which violates basic tenets of the Protestant work ethic; Perceived as an atypical physical feature, aversion may reflect the ‘psychological immune system’ | Discrimination based on weight not prohibited by federal law in the US, seen as violation of cultural norms | Race, gender, ethnicity | Experiences: Internalization of stigma, experience of weight-based teasing among children, adversely affects new dating opportunities and relationships, discrimination in employment, wages and promotions, environmental stigma (environmental cues, such as size of airline seats and hospital beds) that makes non-normative weight highly salient Practices: Social rejection, distancing, biases within healthcare, media presentations of ideals in health and beauty, as well as portraying overweight as an undesirable characteristic | Vulnerability to depression, low self-esteem, poor body image and maladaptive eating, avoidance of physical exercise, strong experiences of anticipated and perceived stigma | Some evidence of under-utilization of healthcare resources, delay and avoidance of preventive care, one state (Michigan) and some cities (e.g. San Francisco, CA and Binghamton, NY) have laws prohibiting discrimination based on weight, limited effectiveness of interventions to reduce weight-based stigma and discrimination | Increased susceptibility to type 2 diabetes and some evidence of threat to cardiovascular health, quality of life |