Stigma As A Fundamental Cause of Population Health Inequalities – AJPH March 2013

Notes from…

Stigma As A Fundamental Cause of Population Health Inequalities – AJPH March 2013

Stigma is defined as a coocurrence of labeling, stereotyping, separation, status loss and discrimination in a context in which power is exercised.

Discrimination at the individual level (i.e., the unequal treatment that arises from membership in a particular social group) and structural level (i.e., societal conditions that constrain an individual’s opportunities, resources, and well being) is a constitutive feature of stigma.

Fundamental cause theory – posits that some social factors remain persistently associated with health inequalities over time despite dramatic changes in diseases, risk factors, and health interventions.

·         A fundamental social cause influences multiple disease outcomes through multiple risk factors among a substantial number of people

·         A fundamental social cause involves access to resources

·         Fundamental social causes are robustly related to health inequalities across time and space

Policies and interventions must address the social factor itself; otherwise fundamental social causes will continually produce health inequalities through the production of new mechanisms.

When trying to understand the impact of stigma for a particular circumstance, such as HIV, it’s important to keep in mind that stigma can affect many life chances, not just one. A full accounting must consider the overall effect of HIV stigma on a multiple outcomes. For example in a particular out (employment) many stigmatizing circumstances may be involved.

** any impairments or deficits associated with a stigmatized statue might also affect an outcome. This poses the possibility that gaps between stigmatized and nonstigmatized groups are attributable not only to stigma, but also to impairments or deficits. For example, diminished earnings among individuals with disabilities could be caused by the disability itself (e.g., disabled individuals working fewer hours) in addition to the stigma of being disabled.

CONFOUNDERS

Stigma represents an added burden that affects people above and beyond any impairments or deficits they may have.

According to fundamental cause theory, SES embodies resources of money, knowledge, power, prestige, and beneficial social connections, and it is by having superior resources that higher SES individuals and groups gain health advantage. The situation of being stigmatized depletes man of these same resources.

Forms of resource discrimination

·         Employment

·         Wages

·         Mortgages and other loans

·         Housing

·         Quality and quantity of education and health care

Identity loss is identified as an essential component of stigmatization

Status Characteristics Theory - in cooperative goal-oriented groups, different status labels (e.g., males and females) reliably produce unequal performance expectations that reproduce (and reinforce) the original status hierarchy - stigma processes have effects on status that are identical to those described in status characteristics theory

Stigma may cause social isolation – fear of rejection and negative evaluation lead individuals with concealable stigmas to avoid entering close relationships for fear of others discovering their stigmatized status.

Salubrious?

Social isolation may be a pathway through which stigma is linked to population health.  Four pathways for mediation:

·         Stigma is linked to poor health

·         Stigma is associated with greater social isolation

·         Social isolation increases risk for poor health outcomes

·         The stigma-health relationship is significantly attenuated after adjustment for social isolation

Psychological and Behavioral Responses to Stigma

Multiple psych and behavioral processes are disrupted by stigma

Self stigmatizing – internalizing those negative societal perceptions of one’s stigmatized status or group – and this can be deleterious to health

Stigmatized individuals use and deplete self control to manage a devalued identity which requires a flexible use of emotion regulation strategies in the short term. Over time however, the effort required to cope with stigma diminishes individuals’ psychological resources and therefore their ability to adaptively regulate their emotions, which can have negative consequences for both mental and physical health.

The experience of stigma can also lead to maladaptive coping behaviors (including smoking and drinking and unsafe sex) that increase risk for adverse health outcomes.

Minority Stress Theory – excess stress to which individuals from stigmatized groups are exposed as a result of their social position. Minority stressor range from external events (e.g., victimization and violence) to internal responses (e.g., expectations of rejection) – both of which are associated with health problems among minority group members

Identity threat models of stigma argue that possessing a stigmatized identity increases exposure to stressful conditions and situations.

In sum, stigma appears to have a corrosive influence on health in large part through disruption and alteration of myriad systems – institutional and communal (material sources and conditions), interpersonal (social relationships), and intrapsychic (self-esteem, coping behaviors) by the stigma process.