Self-regulatory processes underlying structural stigma and health

The importance of self-management for better treatment outcomes for HIV patients in a low-income setting: perspectives of HIV experts and service providers

BACKGROUND

Self-management is the most important strategy to improve quality of life in patients with a chronic disease. Despite the increasing number of people living with HIV (PLWH) in low-income countries, very little research on self-management is conducted in this setting. The aim of this research is to understand the perspectives of service providers and experts on the importance of self-management for PLWH.

METHODS

A systematizing expert interview type of qualitative methodology was used to gain the perspectives of experts and service providers. The study participants had experience in researching, managing, or providing HIV service in east and southern African (ESA) countries. All the interviews were audio recorded, transcribed, and translated to English. The quality of the transcripts was ensured by randomly checking the texts against the audio record. A thematic analysis approach supported by Atlas TI version 9 software.

RESULT

PLWH face a variety of multi-dimensional problems thematized under contextual and process dimensions. The problems identified under the contextual dimension include disease-specific, facility-related, and social environment-related. Problems with individual origin, such as ignorance, outweighing beliefs over scientific issues, low self-esteem, and a lack of social support, were mostly highlighted under the process dimensions. Those problems have a deleterious impact on self-management, treatment outcomes, and the quality of life of PLWH. Low self-management is also a result of professional-centered service delivery in healthcare facilities and health service providers' incapacity to comprehend a patient's need beyond the medical concerns. Participants in the study asserted that patients have a significant stake in enhancing treatment results and quality of life through enhancing self-management.

CONCLUSION AND RECOMMENDATION

HIV patients face multifaceted problems beyond their medical issues. The success of medical treatment for HIV is strongly contingent upon patients' self-management practices and the supportive roles of their family, society, and health service providers. The development and integration of self-management practices into clinical care will benefit patients, their families, and the health system.

Mental health impact of multiple sexually minoritized and gender expansive stressors among LGBTQ+ young adults: a latent class analysis

AIMS

In the United States, lesbian, gay, bisexual, transgender, queer, intersex, asexual and other sexually minoritized and gender expansive (LGBTQ+) young adults are at increased risk for experiencing mental health inequities, including anxiety, depression and psychological distress-related challenges associated with their sexual and gender identities. LGBTQ+ young adults may have unique experiences of sexual and gender minority-related vulnerability because of LGBTQ+-related minority stress and stressors, such as heterosexism, family rejection, identity concealment and internalized homophobia. Identifying and understanding specific LGBTQ+-related minority stress experiences and their complex roles in contributing to mental health burden among LGBTQ+ young adults could inform public health efforts to eliminate mental health inequities experienced by LGBTQ+ young adults. Therefore, this study sought to form empirically based risk profiles (i.e., latent classes) of LGBTQ+ young adults based on their experiences with familial heterosexist experiences, LGBTQ+-related family rejection, internalized LGBTQ+-phobia and LGBTQ+ identity concealment, and then identify associations of derived classes with psychological distress.

METHODS

We recruited and enrolled participants using nonprobability, cross-sectional online survey data collected between May and August 2020 (N = 482). We used a three-step latent class analysis (LCA) approach to identify unique classes of response patterns to LGBTQ+-related minority stressor subscale items (i.e., familial heterosexist experiences, LGBTQ+-related family rejection, internalized LGBTQ+-phobia and LGBTQ+ identity concealment), and multinomial logistic regression to characterize the associations between the derived classes and psychological distress.

RESULTS

Five distinct latent classes emerged from the LCA: (1) low minority stress, (2) LGBTQ+ identity concealment, (3) family rejection, (4) moderate minority stress and (5) high minority stress. Participants who were classified in the high and moderate minority stress classes were more likely to suffer from moderate and severe psychological distress compared to those classified in the low minority stress class. Additionally, relative to those in the low minority stress class, participants who were classified in the LGBTQ+ identity concealment group were more likely to suffer from severe psychological distress.

CONCLUSION

Familial heterosexist experiences, LGBTQ+-related family rejection, internalized LGBTQ+-phobia and LGBTQ+ identity concealment are four constructs that have been extensively examined as predictors for mental health outcomes among LGBTQ+ persons, and our study is among the first to reveal nuanced gradients of these stressors. Additionally, we found that more severe endorsement of minority stress was associated with greater psychological distress. Given our study results and the previously established negative mental health impacts of minority stressors among LGBTQ+ young adults, findings from our study can inform research, practice, and policy reform and development that could prevent and reduce mental health inequities among LGBTQ+ young adults.

Using an intersectionality-based approach to evaluate mental health services use among gay, bisexual and other men who have sex with men in Montreal, Toronto and Vancouver

AIMS

To cope with homonegativity-generated stress, gay, bisexual and other men who have sex with men (GBM) use more mental health services (MHS) compared with heterosexual men. Most previous research on MHS among GBM uses data from largely white HIV-negative samples. Using an intersectionality-based approach, we evaluated the concomitant impact of racialization and HIV stigma on MHS use among GBM, through the mediating role of perceived discrimination (PD).

METHODS

We used baseline data from 2371 GBM enrolled in the Engage cohort study, collected between 2017 and 2019, in Montreal, Toronto and Vancouver, using respondent-driven sampling. The exposure was GBM groups: Group 1 (n = 1376): white HIV-negative; Group 2 (n = 327): white living with HIV; Group 3 (n = 577): racialized as non-white HIV-negative; Group 4 (n = 91): racialized as non-white living with HIV. The mediator was interpersonal PD scores measured using the Everyday Discrimination Scale (5-item version). The outcome was MHS use (yes/no) in the prior 6 months. We fit a three-way decomposition of causal mediation effects utilizing the imputation method for natural effect models. We obtained odds ratios (ORs) for pure direct effect (PDE, unmediated effect), pure indirect effect (PIE, mediated effect), mediated interaction effect (MIE, effect due to interaction between the exposure and mediator) and total effect (TE, overall effect). Analyses controlled for age, chronic mental health condition, Canadian citizenship, being cisgender and city of enrolment.

RESULTS

Mean PD scores were highest for racialized HIV-negative GBM (10.3, SD: 5.0) and lowest for white HIV-negative GBM (8.4, SD: 3.9). MHS use was highest in white GBM living with HIV (GBMHIV) (40.4%) and lowest in racialized HIV-negative GBM (26.9%). Compared with white HIV-negative GBM, white GBMHIV had higher TE (OR: 1.71; 95% CI: 1.27, 2.29) and PDE (OR: 1.68; 95% CI: 1.27, 2.24), and racialized HIV-negative GBM had higher PIE (OR: 1.09; 95% CI: 1.02, 1.17). Effects for racialized GBMHIV did not significantly differ from those of white HIV-negative GBM. MIEs across all groups were comparable.

CONCLUSIONS

Higher MHS use was observed among white GBMHIV compared with white HIV-negative GBM. PD positively mediated MHS use only among racialized HIV-negative GBM. MHS may need to take into account the intersecting impact of homonegativity, racism and HIV stigma on the mental health of GBM.

Erasing stigmas through storytelling: why interactive storytelling environments could reduce health-related stigmas

In this article we describe how designers can apply storytelling to reduce health-related stigmas. Stigma is a pervasive problem for people with illnesses, such as obesity, and it can persistently hinder coping, treatment, recovery, and prevention. Reducing health-related stigma is complex because it is multi-layered and self-perpetuating, leading to intertwined vicious circles. Interactive storytelling environments can break these vicious circles by delimiting the narrative freedom of stigma actors. We theoretically explain the potential of interactive storytelling environments to reduce stigma through the following seven functions: 1) expose participants to other perspectives, 2) provide a protective frame, 3) intervene in daily conversations, 4) persuade all stigma actors, 5) exchange alternative understandings, 6) elicit understanding and support for stigma victims, and 7) support stigma victims to cope with stigmatization. We elaborate on these functions through a demonstration of an interactive storytelling environment against weight stigma. In conclusion, this article is a call on designers for health and wellbeing, scientists, and practitioners from various disciplines to be sensitive to the pervasiveness of stigma and to collaboratively create destigmatizing storytelling environments.

The effect of parental regulatory focus on the loneliness stigma of college children

BACKGROUND

The present study aimed to examine the relationship between regulatory focus and loneliness stigma, as well as the intergenerational transmission of the two. Specifically, the study analyzed the effects of fathers' and mothers' regulatory focus on their own and their spouses' stigma of loneliness. In addition, a mediation model was constructed to explore how parents' regulatory focus influences their children's stigma of loneliness and the potential mediating mechanisms involved.

METHODS

Questionnaires were distributed to 470 college students and their parents, employing the Regulatory Focus Questionnaire (RFQ) and the Stigma of Loneliness Scale (SLS) to collect data.

RESULTS

The analysis of intergenerational transmission effects revealed that parents' regulatory focus and loneliness stigma significantly and positively predicted children's regulatory focus and loneliness stigma, respectively. The Actor-Partner Interdependence Model (APIM) elucidated that both fathers' and mothers' promotion focus exerted significant influence on both actor and partner's loneliness stigma. Furthermore, the mediation model analysis indicated that parents' loneliness stigma, along with children's regulatory focus operate as mediators in the influence of parental regulatory focus on loneliness stigma of their college-aged offspring.

CONCLUSIONS

From a familial context, this study, investigated the association between regulatory focus and loneliness stigma, along with the mediating roles within parent-child groups and couples. The findings enhanced our comprehension of the interrelation between regulatory focus and loneliness stigma, underpinned by empirical evidence.

'It is stigma that makes my work dangerous': experiences and consequences of disclosure, stigma and discrimination among sex workers in Western Australia

Western Australia criminalises sex work whilst some other Australian jurisdictions have decriminalised the industry. This article examines the role of Western Australia's legislation in reinforcing stigma and discrimination of sex workers. It draws on stigma and discrimination-specific results from open-ended survey responses and interview data collected as part of a larger cross-sectional mixed-methods study. Experiences and/or anticipation of stigma and discrimination resulted in some sex workers concealing their involvement in sex work from family, friends and their home communities. This was a major barrier to accessing health care and protective services and impacted negatively on their mental health and wellbeing. There is a need for policy change and support to shift society's perception of sex work to that of a legitimate occupation to decrease sex workers' experiences of stigma and discrimination and improve their access to and utilisation of health care and protective services. These findings highlight the need for the decriminalisation of the Western Australian sex industry and the development of training programmes for police and healthcare workers to reduce the stigma and discrimination experienced by sex workers in these settings.

Contextual influences on Latino men's sexual and substance use behaviors following immigration to the Midwestern United States

Objectives: Latinos in the United States experience a disproportionate number of HIV and other sexually transmitted infections (STIs) and higher use of alcohol and illegal drugs, which has been attributed to increases in risk behaviors following immigration. Whereas substantial research documents these behavioral changes, little is known about how immigrants increase their risk or why some immigrants increase their risk and other immigrants do not. This study explored how the social and normative context affects sexual and substance use behaviors among Latino immigrant men in a midsized Midwestern city of the United States.Methods: We interviewed 64 Latino immigrant men recruited from community sites in Milwaukee, Wisconsin (mean age = 32.6 years). Participants reported the social and normative contexts preceding and following immigration, including social networks and support, perceptions of the law, and familiar and peer normative influences.Results: Immigrants attributed changes in their sexual and substance use behaviors to their immigration goals, social support, peer and familial normative influences, and restrictions related to their immigrant status. Immigration for economic and personal advancement was generally protective from behaviors that would interfere with those goals as were extended familial networks that could provide support, resources, and normative control. The need to stay under the radar of authorities, the proportion of Latinos in the community, the social and normative changes associated with immigrants' age, and the higher perceptions of risk for HIV in the United States compared with their home countries also influenced immigrants' sexual and substance use behaviors.Conclusions: Changes in risk behavior after immigration to the United States reflect a combination of social and normative factors and personal goals. Interventions and policies aiming to prevent HIV and substance use among Latino immigrants should understand the contextual conditions that decrease or increase their risk behaviors in the United States.

Building a resilient public health system for international migrant workers: a case study and policy brief for COVID-19 and beyond

Purpose

This article analyzes deficiencies in public health services for international migrant workers (IMWs) during the COVID-19 pandemic and provides a policy brief for improvement of the public health system.

Design/methodology/approach

A COVID-19 outbreak that initially clustered in IMWs and further contributed to the resurgence of the disease across Thailand in December 2020 was analyzed to address the deficiencies in public health services based on the framework of the 10 Essential Public Health Services (EPHS). The EPHS framework was also applied to develop policy options and recommendations in the subsequent policy brief.

Findings

This outbreak unveiled unique challenges that make IMWs more vulnerable to COVID-19. The public health system, challenged by the COVID-19 outbreak among IMWs, manifested deficiencies in the planning and implementation of all essential services. Delayed detection of the outbreak along with the lack of policy accommodating undocumented IMWs and the lack of equitable access to testing and treatment for COVID-19 resulted in the transmission of the disease that harmed the public at large.

Originality/value

The comprehensive analysis of the deficiencies in public health services for IMWs enabled a clear description of problems that could be further prioritized by relevant stakeholders. The policy brief provides policymakers with evidence-based recommendations for improving public health services for IMWs during the COVID-19 pandemic and beyond.

Perceived Discrimination and Increased Odds of Unmet Medical Needs Among US Children

Our study examines the association between perceived discrimination due to race and unmet medical needs among a nationally representative sample of children in the United States. We used data from the 2016-2017 National Survey of Children's Health, a population-based cross-sectional survey of randomly selected parents or guardians in the United States. We compared results from the coarsened exact matching (CEM) method and survey-weighted logistic regression to assess the robustness of the results. Using self-reported measures from caregivers, we find that ∼2.7% of US children have experienced racial discrimination with prevalence varying significantly by race. While <1% of non-Hispanic whites have experienced some measure of racism, this increases to 8.8% among non-Hispanic blacks. Perceived discrimination was associated with significantly greater odds of unmet medical needs in the adjusted, survey-weighted multivariate-adjusted model (adjusted odds ratio [OR] = 2.4 and 95% confidence interval [CI] = 1.2, 4.9) as well as in the CEM-model estimate (OR = 2.8 and 95% CI = 1.8, 4.0). Children who have experienced perceived discrimination had higher odds of unmet medical needs. Awareness of discrimination among children may help inform future intervention development that addresses unmet medical needs during childhood.

Self-perception of overweight and obesity: A review of mental and physical health outcomes

The obesity crisis is one of the largest public health challenges of the 21st century. Population‐level adiposity has increased dramatically in recent times, and people not recognizing that they have overweight or obesity is now common. It has been widely assumed that not recognizing oneself as having overweight is detrimental to weight management and long‐term health. Here, diverse research is reviewed that converges on the counterintuitive conclusion that not recognizing oneself as having overweight is actually associated with more favourable physical and mental health outcomes than recognizing oneself as having overweight. Drawing on existing models in social psychology and weight stigma research, an explanatory model of the health effects of self‐perception of overweight is outlined. This model proposes that self‐perception of overweight triggers social rejection concerns and the internalization of weight stigma, which in turn induce psychological distress and negatively impact health‐promoting lifestyle behaviours. How self‐perception of overweight may in part explain progression from overweight to obesity, and the public health implications of self‐perception of overweight and obesity are also discussed.

Experiences of racism, sexual objectification and alcohol use among gay and bisexual men of colour

Objective: Previous research has shown that experiences of racial discrimination and sexual objectification are associated with health risk behaviours among gay and bisexual men of colour. However, little is known about whether racial discrimination and sexual objectification are associated with alcohol use among this population. This community-based study examined the association between racial discrimination, sexual objectification and alcohol use in a sample of 369 gay and bisexual men of colour (Black/African/Caribbean, Latino/Latin American, South Asian, and East and Southeast Asian) in Toronto.Design: Data were drawn from an online survey designed to examine issues of racism, homophobia, health and well-being among gay and bisexual men of colour in Toronto. Regression analysis assessed the relationship between scores on the Racism and Life Experiences Scale, Sexual Objectification Scale, and the CAGE questionnaire (a screen for alcohol use disorder).Results: Multivariable logistic regression analyses revealed that experiences of racism and sexual objectification are significantly and positively associated with a screening for alcohol use disorder. The interactions between Latino/Latin American race/ethnicity and experience of sexual objectification were also positively associated with a screening for alcohol use disorder.Conclusions: Health professionals should consider the role of racial discrimination and sexual objectification within the context of risk and treatment for alcohol use disorders, harm reduction, and HIV prevention for gay and bisexual men of colour.

Substance Use Stigma, Primary Care, and the New York State Prescription Drug Monitoring Program

Prescription drug monitoring programs (PDMPs) are databases that track controlled substances at the provider, patient, and pharmacy levels. While these databases are widely available at the state level throughout the United States, several jurisdictions in recent years have mandated the use of these systems by health care providers. This study explores the implementation of mandatory PDMP technology in primary care practice and the effects on treatment of people with possible substance use disorders. Findings are based on 53 in-depth interviews with primary care providers in New York City, collected shortly following the passage of legislation mandating use of a PDMP by health care providers in New York State. Findings suggest that use of the PDMP highlighted tensions between provider stigma toward substance use disorders and the clinical care of people who use drugs, challenging their stereotypes and biases. The parallel clinical and law enforcement purposes of PDMP technology placed providers in dual roles as clinicians and enforcers and encouraged the punitive treatment of patients. Finally, PDMP technology standardized the clinical assessment process toward a "diagnosis first" approach, consistent with prior scholarship on the implementation of emerging medical technologies.

Buffering Internalization of HIV Stigma: Implications for Treatment Adherence and Depression

BACKGROUND

One mechanism through which social stigma of HIV affects health outcomes for people living with HIV (PLWH) is through internalization of stigma. However, this transformation of social stigma in the community into internalized stigma may not be of the same magnitude for all PLWH. We examined the moderating effects of 3 personality traits-fear of negative social evaluation, attachment-related anxiety, and dispositional resilience-in transforming perceived stigma in the community into internalized stigma. Furthermore, we investigated downstream effects of these moderated associations on depressive symptoms and antiretroviral treatment (ART) adherence.

SETTING/METHODS

In study 1, data from 203 PLWH in the Southeast United States were analyzed controlling for age, sex, education, race, and time on ART. In study 2, data from 453 women in a multisite study were analyzed controlling for age, education, race, time on ART, and substance use.

RESULTS

In both studies, fear of negative evaluation and attachment-related anxiety moderated the effect of perceived HIV stigma in the community on internalized HIV stigma: People higher on those moderating variables had stronger associations between perceived stigma in the community and internalized stigma. In study 2, resilience was assessed and also moderated the effect of perceived HIV stigma in the community on internalized stigma. In moderated mediation models, fear of negative evaluation, attachment-related anxiety, and resilience moderated the indirect effect of perceived HIV stigma in the community on ART adherence and depression through internalized stigma.

CONCLUSIONS

Interventions to assuage internalization of HIV stigma should focus on bolstering attachment-related security, social competence, and resilience.

Review of the effects of self-stigma and perceived social stigma on the treatment-seeking decisions of individuals with drug- and alcohol-use disorders

Substance-use disorders are a public health crisis globally and carry with them significant morbidity and mortality. Stigma toward people who abuse these substances, as well as the internalization of that stigma by substance users, is widespread. In this review, we synthesized the available evidence for the role of perceived social stigma and self-stigma in people’s willingness to seek treatment. While stigma may be frequently cited as a barrier to treatment in some samples, the degree of its impact on decision-making regarding treatment varied widely. More research needs to be done to standardize the definition and measurement of self- and perceived social stigma to fully determine the magnitude of their effect on treatment-seeking decisions.

Racism and health service utilisation: A systematic review and meta-analysis

Although racism has been posited as driver of racial/ethnic inequities in healthcare, the relationship between racism and health service use and experience has yet to be systematically reviewed or meta-analysed. This paper presents a systematic review and meta-analysis of quantitative empirical studies that report associations between self-reported racism and various measures of healthcare service utilisation. Data were reviewed and extracted from 83 papers reporting 70 studies. Studies included 250,850 participants and were conducted predominately in the U.S. The meta-analysis included 59 papers reporting 52 studies, which were analysed using random effects models and mean weighted effect sizes. Racism was associated with more negative patient experiences of health services (HSU-E) (OR = 0.351 (95% CI [0.236,0.521], k = 19), including lower levels of healthcare-related trust, satisfaction, and communication. Racism was not associated with health service use (HSU-U) as an outcome group, and was not associated with most individual HSU-U outcomes, including having had examinations, health service visits and admissions to health professionals and services. Racism was associated with health service use outcomes such as delaying/not getting healthcare, and lack of adherence to treatment uptake, although these effects may be influenced by a small sample of studies, and publication bias, respectively. Limitations to the literature reviewed in terms of study designs, sampling methods and measurements are discussed along with suggested future directions in the field.

Sexual Orientation-Based Discrimination, Excessive Alcohol Use, and Substance Use Disorders Among Sexual Minority Adults

PURPOSE

The purpose of this study was to examine relationships between sexual orientation-based discrimination and excessive alcohol use and substance use disorders and to identify how these relationships differ by sexual identity, sex, race, Hispanic origin, and education among sexual minorities.

METHODS

We used logistic regression to analyze associations between discrimination and substance use measures among 1351 gay/lesbian, bisexual, or unsure adults from a nationally representative survey. Differential effects by sexual identity, sex, race, Hispanic origin, and education were assessed using interaction models followed by stratified models.

RESULTS

Discrimination was associated with increased odds of the following: exceeding weekly drinking limits [adjusted odds ratio (aOR) = 1.52, 95% confidence interval (CI): 1.12-2.08] among bisexuals, any substance use disorder (aOR = 2.04, 95% CI: 1.41-2.95) and nicotine use disorder (aOR = 1.52, 95% CI: 1.08-2.14) among Hispanic sexual minorities, and exceeding weekly drinking limits (aOR = 1.56, 95% CI: 1.08-2.26) among those with a high school degree or less.

CONCLUSION

Sexual orientation-based discrimination was associated with select substance use outcomes, especially among bisexuals, Hispanics, and less educated sexual minority adults, highlighting potential disparities associated with experiencing discrimination.

What reduces sexual minority stress? A review of the intervention "toolkit"

Sexual orientation health disparities are rooted in sexual minorities' exposure to stress and challenges to effective coping. This paper reviews the "toolkit" of psychosocial interventions available to reduce sexual minority stress effects. A systematic search uncovered 44 interventions that both seek to reduce sexual minority stress at its source in unjust and discriminatory social structures as well as bolster sexual minorities' stigma-coping abilities. These interventions were implemented in a variety of contexts (e.g., education, health care delivery) and utilized heterogeneous modalities to create change (e.g., policy implementation, role-playing activities). They were designed to affect change across structural, interpersonal, and individual levels. The interventions reviewed here, while in early stages of efficacy testing, possess potential for meeting the needs and resources of mental and medical health care providers, policy makers, and other stakeholders who aim to lessen the burden of sexual minority stress and the health disparities it generates.

Health care barriers, racism, and intersectionality in Australia

While racism has been shown to negatively affect health care quality, little is known about the extent to which racial discrimination works with and through gender, class, and sexuality to predict barriers to health care (e.g., perceived difficulty accessing health services). Additionally, most existing studies focus on racial disparities in the U.S. context, with few examining marginalized groups in other countries. To address these knowledge gaps, we analyze data from the 2014 Australian General Social Survey, a nationally representative survey of individuals aged 15 and older living in 12,932 private dwellings. Following an intersectional perspective, we estimate a series of multivariable logit regression models to assess three hypotheses: racial discrimination will be positively associated with perceived barriers to health care (H1); the effect of perceived racial discrimination will be particularly severe for women, sexual minorities, and low socio-economic status individuals (H2); and, in addition to racial discrimination, other forms of perceived discrimination will negatively impact perceived barriers to health care (H3). Findings show that perceptions of racial discrimination are significantly associated with perceived barriers to health care, though this relationship is not significantly stronger for low status groups. In addition, our analyses reveal that perceived racism and other forms of discrimination combine to predict perceived barriers to health care. Taken together, these results speak to the benefits of an intersectional approach for examining racial inequalities in perceived access to health care.

Gender discrimination, educational attainment, and illicit drug use among U.S. women

PURPOSE

While gender inequality has been a topic of concern for decades, little is known about the relationship between gender discrimination and illicit drug use. Further, whether this association varies by education level is unknown.

METHODS

Among 19,209 women participants in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (2004-2005), we used logistic regression to test the association between gender discrimination (measured with four items from the Experiences of Discrimination instrument) and three outcomes: past-year illicit drug use, frequent drug use, and drug use disorders. We then tested whether associations differed by education level.

RESULTS

Gender discrimination was reported by 9% of women and was associated with past-year drug use [adjusted odds ratio (aOR) = 2.67; 95% confidence interval (CI) 2.17-3.29], frequent drug use (aOR = 2.82; CI 1.99-4.00), and past-year drug use disorders (aOR = 3.15; CI 2.16-4.61). All specific domains of gender discrimination (on the job, in public, with institutions, being called a sexist name) were associated with all drug use outcomes. The association between gender discrimination and past-year drug use was stronger among women with less than a high school education (aOR = 6.33; CI 3.38-11.85) compared to those with more education (aOR = 2.45; CI 1.97-3.04; p _interaction < 0.01).

CONCLUSIONS

Gender discrimination is consistently and strongly associated with illicit drug use and drug use disorders among U.S. women, with significantly higher odds for drug use among women with less than a high school education. Future research should examine whether explicitly addressing distress from discrimination could benefit women in drug treatment, especially among clients with lower educational attainment.

Structural stigma: Research evidence and implications for psychological science

Psychological research has provided essential insights into how stigma operates to disadvantage those who are targeted by it. At the same time, stigma research has been criticized for being too focused on the perceptions of stigmatized individuals and on microlevel interactions, rather than attending to structural forms of stigma. This article describes the relatively new field of research on structural stigma, which is defined as societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized. I review emerging evidence that structural stigma related to mental illness and sexual orientation (a) exerts direct and synergistic effects on stigma processes that have long been the focus of psychological inquiry (e.g., concealment, rejection sensitivity), (b) serves as a contextual moderator of the efficacy of psychological interventions, and (c) contributes to numerous adverse health outcomes for members of stigmatized groups-ranging from dysregulated physiological stress responses to premature mortality-indicating that structural stigma represents an underrecognized mechanism producing health inequalities. Each of these pieces of evidence suggests that structural stigma is relevant to psychology and therefore deserves the attention of psychological scientists interested in understanding and ultimately reducing the negative effects of stigma. (PsycINFO Database Record

Answering the call to accessible quality health care for all using a new model of local community not-for-profit charity clinics: A return to Christ-centered care of the past

This article uses studies and organizational trends to understand available solutions to the lack of quality health care access, especially for the poor and needy of local U.S. communities. The U.S. healthcare system seems to be moving toward the World Health Organization's recommendation for universal health coverage for healthcare sustainability. Healthcare trends and offered solutions are varied. Christian healthcare traditionally implements works of mercy guided by a Christian ethos embracing the teachings of human dignity, solidarity, the common good, and subsidiarity. Culture of Life Ministries is one of many new sustainable U.S. healthcare models which implements Christ-centered health care to meet the need of quality and accessible health care for the local community. Culture of Life Ministries employs a model of charity care through volunteerism. Volunteer workers not only improve but also transform the local healthcare system into a personal healing ministry of the highest quality for every person. Summary: The lack of access to quality health care is a common problem in the U.S. despite various solutions offered through legislative and socioeconomic works: universal healthcare models, insurance models, and other business models. U.S. health care would be best transformed by returning to the implementation of a traditional system founded on the Christian principles of human dignity, solidarity, subsidiarity, and the common good. Culture of Life Ministries is an example of such a local ministry in Texas, which has found success in practically applying these Christ-centered, healthcare principles into an emerging not-for-profit, economically sustainable, healthcare model.

Discrimination, Racial/Ethnic Identity, and Substance Use Among Latina/os: Are They Gendered?

BACKGROUND

Prior research suggests that stronger racial/ethnic identification offsets negative effects of discrimination on substance use. Yet research in this area and on whether gender modifies this association is limited for Latina/os.

PURPOSE

The purpose of the present study is to examine whether different sources of discrimination (everyday and racial/ethnic) are associated with substance use (alcohol use disorder, smoking), if racial/ethnic identity buffers this association, and the potential moderating role of gender among these variables.

METHODS

We present cross-sectional, US population-based data from the Latina/o adult sample (1427 females and 1127 males) of the National Latino and Asian American Study. Respondents completed self-reported measures of everyday and racial/ethnic discrimination, racial/ethnic identity, smoking status, and Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) lifetime alcohol use disorder.

RESULTS

Weighted logistic regression analyses showed that before inclusion of three-way interactions and adjusting for covariates, everyday discrimination predicted increased risk for any DSM-IV lifetime alcohol use disorders. Moderation analyses revealed that the effect of everyday discrimination on the risk of being a current smoker was strongest for Latino men with high levels of racial/ethnic identity compared to those with low racial/ethnic identity. No differences were noted among Latino women. There were no main or interaction effects of racial/ethnic discrimination for any substance use outcome.

CONCLUSIONS

Findings suggest differential associations for type of discrimination and outcome and that the role of racial/ethnic identity is gender-specific for smoking, appearing particularly detrimental for Latino men reporting high levels of racial/ethnic identity.

Assessing mediators between discrimination, health behaviours and physical health outcomes: a representative cross-sectional study

PURPOSE

Discrimination is a social determinant of health; however, the pathways linking discrimination to ill-health are under-researched. This study investigated the mediators through which discrimination affects health behaviours and physical health outcomes, as well as assessed whether sex moderated these mechanisms.

METHODS

Data from a representative survey (n = 1023) of undergraduate students enrolled in a Brazilian university in 2012 were used. Structural equation models were applied to assess the following mediation mechanisms--(1) discrimination influences self-rated health and body mass index via anxiety/depression; (2) discrimination affects behaviours (alcohol consumption, problem drinking, smoking, fruit/vegetable consumption, and physical activity) through discomfort associated with discriminatory experiences. The potential of sex to act as an effect-modifying variable was also explored in each of the postulated pathways.

RESULTS

The effect of discrimination on self-rated poor health was totally (100.0%) mediated by anxiety/depression, while body mass index was not correlated with discrimination. Self-reported discrimination was associated with some behaviours via discomfort. Particularly, discomfort partially mediated the positive association between discrimination, leisure time physical activity (43.3%), and fruit/vegetable consumption (52.2%). Sex modified the association between discrimination, discomfort and physical activity in that such mechanism (more discrimination → more discomfort → more physical activity) was statistically significant in the entire sample and among females, but not among males.

CONCLUSIONS

This is one of the first studies to demonstrate that discrimination is associated with physical health outcomes and behaviours via distinct pathways. Future investigations should further explicate the mediational pathways between discrimination and key health outcomes.

The Stigma Complex

Since the beginning of the twenty-first century, research on stigma has continued. Building on conceptual and empirical work, the recent period clarifies new types of stigmas, expansion of measures, identification of new directions, and increasingly complex levels. Standard beliefs have been challenged, the relationship between stigma research and public debates reconsidered, and new scientific foundations for policy and programs suggested. We begin with a summary of the most recent Annual Review articles on stigma, which reminded sociologists of conceptual tools, informed them of developments from academic neighbors, and claimed findings from the early period of "resurgence." Continued (even accelerated) progress has also revealed a central problem. Terms and measures are often used interchangeably, leading to confusion and decreasing accumulated knowledge. Drawing from this work but focusing on the past 14 years of stigma research (including mental illness, sexual orientation, HIV/AIDS, and race/ethnicity), we provide a theoretical architecture of concepts (e.g., prejudice, experienced/received discrimination), drawn together through a stigma process (i.e., stigmatization), based on four theoretical premises. Many characteristics of the mark (e.g., discredited, concealable) and variants (i.e., stigma types and targets) become the focus of increasingly specific and multidimensional definitions. Drawing from complex and systems science, we propose a stigma complex, a system of interrelated, heterogeneous parts bringing together insights across disciplines to provide a more realistic and complicated sense of the challenge facing research and change efforts. The Framework Integrating Normative Influences on Stigma (FINIS) offers a multilevel approach that can be tailored to stigmatized statuses. Finally, we outline challenges for the next phase of stigma research, with the goal of continuing scientific activity that enhances our understanding of stigma and builds the scientific foundation for efforts to reduce intolerance.