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Inman EM, Nkala-Dlamini B, Violari A, Kidman R. HIV Stigma, Health, and Violence: A Longitudinal Study among Adolescent Boys with HIV in Soweto, South Africa. AIDS Behav 2024:10.1007/s10461-024-04407-x. [PMID: 38856845 DOI: 10.1007/s10461-024-04407-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2024] [Indexed: 06/11/2024]
Abstract
There are over 1.4 million adolescents living with HIV in sub-Saharan Africa, the majority of whom acquired the virus through perinatal transmission (PHIV). HIV stigma is particularly high among adolescents living with HIV and is associated with several outcomes that worsen health and increase the risk of onward HIV transmission. We tested associations between internalized HIV stigma and four of these outcomes over a one-year period among a sample of adolescent boys living with PHIV in Soweto, South Africa. Participants (N = 241) answered questions about internalized HIV stigma at baseline. They completed weekly mobile surveys over the following year to answer questions about their experiences with depression, binge drinking, medication adherence, and violence victimization. Using generalized linear mixed models, we found that baseline internalized HIV stigma was associated with increased odds of depression (OR 1.74), alcohol misuse (OR 2.09), and violence victimization (OR 1.44) and decreased odds of medication adherence (OR 0.60) over the course of a year. These outcomes negatively impact the health and wellbeing of adolescents living with PHIV and increase their risk of transmitting HIV to their partners in the future. Our findings provide novel, longitudinal evidence for the deleterious effects of HIV stigma. To improve health outcomes for adolescents with PHIV, it will be crucial to develop effective HIV stigma reduction interventions that address specific developmental, gendered, and cultural experiences.
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Affiliation(s)
- Elizabeth M Inman
- Program in Public Health, State University of New York at Stony Brook, Stony Brook, NY, 11794, USA.
| | - Busisiwe Nkala-Dlamini
- Department of Social Work, Faculty of Humanities, University of the Witwatersrand, Johannesburg, 2000, South Africa
| | - Avy Violari
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 1864, South Africa
| | - Rachel Kidman
- Program in Public Health, State University of New York at Stony Brook, Stony Brook, NY, 11794, USA
- Department of Family, Population and Preventive Medicine, State University of New York at Stony Brook, Stony Brook, NY, 11794, USA
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van der Kooij YL, den Daas C, Bos AER, Willems RA, Stutterheim SE. Correlates of Internalized HIV Stigma: A Comprehensive Systematic Review. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2023; 35:158-172. [PMID: 37129595 DOI: 10.1521/aeap.2023.35.2.158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Internalized HIV stigma is prevalent and research on internalized HIV stigma has increased during the past 10 years. The aim of this systematic review was to synthesize research on internalized HIV stigma and relationships with various health-related variables in order to better inform the development of interventions aimed at reducing internalized HIV stigma. We reviewed 176 studies with a quantitative design reporting correlates that were peer-reviewed, published in English before January 2021, drawn from PubMed, PSYCHINFO, Web of Science, EBSCO, and Scopus. Synthesis showed consistent associations between internalized stigma and negative psychological (e.g., depression, anxiety), social (e.g., lack of social support, discrimination, nondisclosure, and intersecting stigmas), and health (e.g., substance use, treatment nonadherence, negative clinical HIV outcomes) variables. We argue for a more socioecological approach to internalized stigma, with greater attention for intersectional stigmas, and more longitudinal research, if we are to effectively develop interventions that reduce internalized stigma.
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Affiliation(s)
| | - Chantal den Daas
- Institute of Applied Health Sciences, Health Psychology Group, Aberdeen University, Aberdeen, Scotland and the National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | | | | | - Sarah E Stutterheim
- Sarah E. Stutterheim is affilkiated with the Department of Health Promotion & Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
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Price MA, Hollinsaid NL. Future Directions in Mental Health Treatment with Stigmatized Youth. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2022; 51:810-825. [PMID: 36007234 PMCID: PMC9835015 DOI: 10.1080/15374416.2022.2109652] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Stigma refers to societally-deemed inferiority associated with a circumstance, behavior, status, or identity. It manifests internally, interpersonally, and structurally. Decades of research indicate that all forms of stigma are associated with heightened risk for mental health problems (e.g., depression, PTSD, suicidality) in stigmatized youth (i.e., children, adolescents, and young adults with one or more stigmatized identities, such as youth of Color and transgender youth). Notably, studies find that stigmatized youth living in places with high structural stigma - defined as laws/policies and norms/attitudes that hurt stigmatized people - have a harder time accessing mental health treatment and are less able to benefit from it. In order to reduce youth mental health inequities, it is imperative for our field to better understand, and ultimately address, stigma at each of these levels. To facilitate this endeavor, we briefly review research on stigma and youth mental health treatment, with an emphasis on structural stigma, and present three future directions for research in this area: (1) directly addressing stigma in treatment, (2) training therapists in culturally responsive care, and (3) structural interventions. We conclude with recommendations for best practices in broader mental health treatment research.
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Affiliation(s)
- Maggi A. Price
- School of Social Work, Boston College, Boston, MA
- Department of Psychology, Harvard University, Cambridge, MA
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Cluver LD, Sherr L, Toska E, Zhou S, Mellins CA, Omigbodun O, Li X, Bojo S, Thurman T, Ameyan W, Desmond C, Willis N, Laurenzi C, Nombewu A, Tomlinson M, Myeketsi N. From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:582-592. [PMID: 35750063 DOI: 10.1016/s2352-4642(22)00101-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 01/10/2023]
Abstract
Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.
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Affiliation(s)
- Lucie D Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
| | - Lorraine Sherr
- Institute of Global Health, University College London, London, UK
| | - Elona Toska
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK; Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Siyanai Zhou
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Claude-Ann Mellins
- HIV Center for Clinical and Behavioral Studies, Department of Psychiatry, New York State Psychiatric Institute, New York, NY, USA; Columbia University Irving Medical Center, New York, NY, USA
| | - Olayinka Omigbodun
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Xiaoming Li
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Samuel Bojo
- Agency for Research and Development Initiative, Juba, South Sudan
| | - Tonya Thurman
- Highly Vulnerable Children Research Center, Cape Town, South Africa; Tulane University School of Public Health, New Orleans, LA, USA
| | - Wole Ameyan
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Chris Desmond
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | | | - Christina Laurenzi
- Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Amahle Nombewu
- Teen Advisory Group, University of Cape Town, Cape Town, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa; School of Nursing and Midwifery, Queens University, Belfast, UK
| | - Noxolo Myeketsi
- Department of Information Systems, University of the Western Cape, Cape Town, South Africa
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Makhakhe NF, Sliep Y, Meyer-Weitz A. “Whatever is in the ARVs, is Also in the PrEP” Challenges Associated With Oral Pre-exposure Prophylaxis Use Among Female Sex Workers in South Africa. Front Public Health 2022; 10:691729. [PMID: 35784260 PMCID: PMC9247347 DOI: 10.3389/fpubh.2022.691729] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background The national policy on oral pre-exposure prophylaxis (PrEP) for female sex workers (FSWs) was instituted in South Africa in 2016. FSWs were targeted for PrEP due to a Human immunodeficiency virus (HIV) prevalence of 57.7%, which is higher than the prevalence of 19.07% among the general population. Research from demonstration studies has shown that uptake of PrEP has been slower than anticipated, and the purpose of this study was to explore barriers to the uptake of PrEP among FSWs. Methods An in-depth qualitative study was conducted with 39 participants, 30 individual participants, and nine focus group participants. Eleven participants consisted of peer educators and two health workers from a sex work and PrEP distribution organization, the rest of the participants (1) were FSWs. Results The majority of participants mentioned that little distinction was made between PrEP and antiretrovirals (ARVs) taken by FSWs living with HIV. PrEP was not distributed through public health care facilities, and health workers unknowingly labeled PrEP as ARVs. Consequently, health workers seen as experts created suspicion and contributed to the mistrust of PrEP among FSWs due to mixed messages, and equating PrEP to ARVs reduced uptake. Furthermore, failure to make a clear distinction between oral PrEP and ARVs resulted in accusations of lying, denialism, and deception leveled at users of PrEP by FSWs using ARVs, and sometimes by clients and intimate partners. FSWs using PrEP reported feeling stigmatized and thrust into interpersonal conflict with their peers after choosing PrEP, leading to broken relationships, and some resorting to taking PrEP privately or discontinuing PrEP altogether. Conclusion Pre-exposure prophylaxis as an ARV targeted for the prevention of HIV among high-risk groups was found to be stigmatizing. The distinctive use of PrEP and ARVs should be correctly explained to users to minimize confusion, enable differentiation and reduce interpersonal conflict. Cohesion among sex work organizations and public health care facilities is needed to disseminate the correct knowledge on PrEP. A non-stigmatizing approach to the distribution of PrEP may serve to increase uptake and adherence.
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Affiliation(s)
- Nosipho Faith Makhakhe
- Faculty of Arts and Design, Center for General Education, Durban University of Technology, Durban, South Africa
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
- *Correspondence: Nosipho Faith Makhakhe ;
| | - Yvonne Sliep
- Department of Psychology, School of Applied Human Sciences, Howard College, University of KwaZulu-Natal, Durban, South Africa
| | - Anna Meyer-Weitz
- Department of Psychology, School of Applied Human Sciences, Howard College, University of KwaZulu-Natal, Durban, South Africa
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Internalized stigma, depressive symptoms, and the modifying role of antiretroviral therapy: A cohort study in rural Uganda. SSM - MENTAL HEALTH 2021; 1. [PMID: 35252904 PMCID: PMC8896824 DOI: 10.1016/j.ssmmh.2021.100034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Depression affects over 40% of people with HIV (PHIV) in low- and middle-income countries, and over half of PHIV report HIV-related internalized stigma. However, few longitudinal studies of PHIV have examined the relationship between HIV-related stigma and depression. Data were analyzed from the 2007–15 Uganda AIDS Rural Treatment Outcomes (UARTO) Study, a cohort of 454 antiretroviral therapy (ART)-naïve PHIV (68% women) starting ART. Our primary outcome was depression symptom severity over the first two years of ART, measured using a locally adapted version of the Hopkins Symptom Checklist; our primary exposure was the 6-item Internalized AIDS-Related Stigma Scale. Both scores were measured at enrollment and at quarterly follow-up visits. We fit linear generalized estimating equations (GEE) regression models to estimate the association between stigma and depression symptom severity, adjusting for potential confounders. We included a stigma×time product term to assess the modifying effect of ART on the association between internalized stigma and depression symptom severity. UARTO participants had a median age of 32 years and median enrollment CD4 count of 217 cells/mm3. Both depression symptom severity and internalized stigma declined on ART, particularly during the first treatment year. In multivariable regression models, depression symptom severity was positively associated with internalized stigma (b=0.03; 95% confidence interval [CI], 0.02 to 0.04) and negatively associated with ART duration >6 months (b =− 0.16; 95% CI,− 0.19 to −0.13). The estimated product term coefficient was negative and statistically significant (P = 0.004), suggesting that the association between internalized stigma and depression symptom severity weakened over time on ART. Thus, in this large cohort of PHIV initiating ART in rural Uganda, depression symptom severity was associated with internalized stigma but the association declined with time on ART. These findings underscore the potential value of ART as a stigma reduction intervention for PHIV, particularly during early treatment.
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Enane LA, Apondi E, Omollo M, Toromo JJ, Bakari S, Aluoch J, Morris C, Kantor R, Braitstein P, Fortenberry JD, Nyandiko WM, Wools‐Kaloustian K, Elul B, Vreeman RC. "I just keep quiet about it and act as if everything is alright" - The cascade from trauma to disengagement among adolescents living with HIV in western Kenya. J Int AIDS Soc 2021; 24:e25695. [PMID: 33838007 PMCID: PMC8035676 DOI: 10.1002/jia2.25695] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 02/22/2021] [Accepted: 03/02/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION There are approximately 1.7 million adolescents living with HIV (ALHIV, ages 10 to 19) globally, including 110,000 in Kenya. While ALHIV experience poor retention in care, limited data exist on factors underlying disengagement. We investigated the burden of trauma among disengaged ALHIV in western Kenya, and its potential role in HIV care disengagement. METHODS We performed in-depth qualitative interviews with ALHIV who had disengaged from care at two sites, their caregivers and healthcare workers (HCW) at 10 sites, from 2018 to 2020. Disengagement was defined as not attending clinic ≥60 days past a missed scheduled visit. ALHIV and their caregivers were traced through phone calls and home visits. Interviews ascertained barriers and facilitators to adolescent retention in HIV care. Dedicated questions elicited narratives surrounding traumatic experiences, and the ways in which these did or did not impact retention in care. Through thematic analysis, a conceptual model emerged for a cascade from adolescent experience of trauma to disengagement from HIV care. RESULTS Interviews were conducted with 42 disengaged ALHIV, 34 caregivers and 28 HCW. ALHIV experienced a high burden of trauma from a range of stressors, including experiences at HIV disclosure or diagnosis, the loss of parents, enacted stigma and physical or sexual violence. A confluence of factors - trauma, stigma and isolation, and lack of social support - led to hopelessness and depression. These factors compounded each other, and resulted in complex mental health burdens, poor antiretroviral adherence and care disengagement. HCW approaches aligned with the factors in this model, suggesting that these areas represent targets for intervention and provision of trauma-informed care. CONCLUSIONS Trauma is a major factor underlying disengagement from HIV care among Kenyan adolescents. We describe a cascade of factors representing areas for intervention to support mental health and retention in HIV care. These include not only the provision of mental healthcare, but also preventing or addressing violence, trauma and stigma, and reinforcing social and familial support surrounding vulnerable adolescents. In this conceptualization, supporting retention in HIV care requires a trauma-informed approach, both in the individualized care of ALHIV and in the development of strategies and policies to support adolescent health outcomes.
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Affiliation(s)
- Leslie A Enane
- The Ryan White Center for Pediatric Infectious Disease and Global HealthDepartment of PediatricsIndiana University School of MedicineIndianapolisINUSA
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Moi Teaching and Referral HospitalEldoretKenya
| | - Mark Omollo
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Judith J Toromo
- The Ryan White Center for Pediatric Infectious Disease and Global HealthDepartment of PediatricsIndiana University School of MedicineIndianapolisINUSA
| | - Salim Bakari
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Josephine Aluoch
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Clemette Morris
- Indiana University‐Purdue University‐IndianapolisIndiana UniversityIndianapolisINUSA
| | - Rami Kantor
- Division of Infectious DiseasesDepartment of MedicineBrown University Apert Medical SchoolProvidenceRIUSA
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Department of EpidemiologyIndiana University Fairbanks School of Public HealthIndianapolisINUSA
- Dalla Lana School of Public HealthDivision of EpidemiologyUniversity of TorontoTorontoONCanada
- Department of MedicineCollege of Health SciencesSchool of MedicineMoi UniversityEldoretKenya
| | - J Dennis Fortenberry
- Division of Adolescent MedicineDepartment of PediatricsIndiana University School of MedicineIndianapolisINUSA
| | - Winstone M Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Department of Child Health and PediatricsCollege of Health SciencesSchool of MedicineMoi UniversityEldoretKenya
| | - Kara Wools‐Kaloustian
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Division of Infectious DiseasesDepartment of MedicineIndiana University School of MedicineIndianapolisINUSA
| | - Batya Elul
- Department of EpidemiologyMailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Rachel C Vreeman
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Division of Infectious DiseasesDepartment of MedicineIndiana University School of MedicineIndianapolisINUSA
- Department of Health System Design and Global HealthIcahn School of Medicine at Mount SinaiNew YorkNYUSA
- Arnhold Institute for Global HealthNew YorkNYUSA
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Li H, Zheng L, Le H, Zhuo L, Wu Q, Ma G, Tao H. The Mediating Role of Internalized Stigma and Shame on the Relationship between COVID-19 Related Discrimination and Mental Health Outcomes among Back-to-School Students in Wuhan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17249237. [PMID: 33321881 PMCID: PMC7764740 DOI: 10.3390/ijerph17249237] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 12/12/2022]
Abstract
Outbreaks of an epidemic, such as coronavirus disease 2019 (COVID-19), always brings about far-ranging discrimination and stigmatization to the epicenter. This was a cross-sectional survey conducted to assess experienced discrimination, internalized stigma, shame, and mental health (anxiety, depression, distress, insomnia) among college students who merely had a perceived linkage with COVID-19, and explore the linkage between discrimination and negative mental health outcomes through the mediating effects of shame and internalized stigma. A total of 995 participants (53% female) were involved in this study, in which 40.9% of college students were reported to be discriminated against because of their experience in Wuhan. The experience of COVID-19-related discrimination is indirectly associated with anxiety, depression, and insomnia, in which shame and internalized stigma play a complete mediating effect. Meanwhile, it is both directly and indirectly associated with distress through shame and internalized stigma. The findings of this study suggest that COVID-19-related discrimination is associated with shame and internalized stigma, which in turn predict psychological symptoms over time.
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