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Friedman SR, Williams LD, Guarino H, Mateu-Gelabert P, Krawczyk N, Hamilton L, Walters SM, Ezell JM, Khan M, Di Iorio J, Yang LH, Earnshaw VA. The stigma system: How sociopolitical domination, scapegoating, and stigma shape public health. JOURNAL OF COMMUNITY PSYCHOLOGY 2022; 50:385-408. [PMID: 34115390 PMCID: PMC8664901 DOI: 10.1002/jcop.22581] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/07/2021] [Accepted: 03/14/2021] [Indexed: 05/26/2023]
Abstract
Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.
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Affiliation(s)
- Samuel R Friedman
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Leslie D Williams
- Division of Community Health Sciences, University of Illinois at Chicago School of Public Health, Chicago, Illinois, USA
| | - Honoria Guarino
- Institute for Implementation Science in Population Health, CUNY Graduate School of Public Health & Health Policy, New York, New York, USA
| | - Pedro Mateu-Gelabert
- Institute for Implementation Science in Population Health, CUNY Graduate School of Public Health & Health Policy, New York, New York, USA
| | - Noa Krawczyk
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Leah Hamilton
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Suzan M Walters
- NYU Rory Meyers College of Nursing, Interdisciplinary Research Training Institute on Hispanic Drug Abuse, University of Southern California, Los Angeles, California, USA
| | - Jerel M Ezell
- Department of Sociology, University of Chicago, Chicago, Illinois, USA
- Department of Medicine, Section on Global Health and Infectious Diseases, University of Chicago, Chicago, Illinois, USA
| | - Maria Khan
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Jorgelina Di Iorio
- Faculty of Psychology and Intercambios Civil Association, CONICET/Buenos Aires University, Buenos Aires, Argentina
| | - Lawrence H Yang
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Valerie A Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, Delaware, USA
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Ezell JM, Walters S, Friedman SR, Bolinski R, Jenkins WD, Schneider J, Link B, Pho MT. Stigmatize the use, not the user? Attitudes on opioid use, drug injection, treatment, and overdose prevention in rural communities. Soc Sci Med 2020; 268:113470. [PMID: 33253992 DOI: 10.1016/j.socscimed.2020.113470] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 10/23/2022]
Abstract
Stigma is a known barrier to treating substance use disorders and dramatically diminishes the quality of life of people who use drugs (PWUD) nonmedically. Stigma against PWUD may be especially pronounced in rural areas due to their decreased anonymity and residents' limited access, or resistance, to "neutralizing" information on factors associated with drug use. Stigma often manifests in the attitudes of professionals whom stigmatized individuals regularly interact with and often materially impact. We analyzed interviews conducted between July 2018 and February 2019 with professional stakeholders in rural southern Illinois who interact with PWUD, specifically those who use opioids nonmedically or who inject drugs (n = 30). We further analyzed interview data from a complementary PWUD sample (n = 22). Interviews addressed perspectives around nonmedical drug use and treatment/harm reduction, with analysis centered around the Framework Integrating Normative Influences on Stigma and its focus on micro, meso and macro level stigmatization processes. Stakeholder participants included professionals from local law enforcement, courts, healthcare organizations, emergency management services, and faith-based and social services organizations. Most stakeholders, particularly law enforcement, negatively perceived PWUD and nonmedical drug use in general, questioned the character, agency and extrinsic value of PWUD, and used labels (e.g. "addict," "abuser," etc.) that may be regarded as stigmatizing. Further, most respondents, including PWUD, characterized their communities as largely unaware or dismissive of the bio-medical and sociocultural explanations for opioid use, drug injection and towards harm reduction services (e.g., syringe exchanges) and naloxone, which were frequently framed as undeserved usages of taxpayer funds. In conclusion, rural stigma against PWUD manifested and was framed as a substantial issue, notably activating at micro, meso and macro levels. Stigma prevention efforts in these communities should aim to improve public knowledge on the intricate factors contributing to opioid use and drug injection and harm reduction programming's moral and fiscal value.
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Affiliation(s)
- Jerel M Ezell
- Africana Studies and Research Center, Cornell University, Ithaca, NY, USA; Cornell Center for Health Equity, Cornell University, Ithaca, NY, USA.
| | - Suzan Walters
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Samuel R Friedman
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Rebecca Bolinski
- Department of Sociology, Southern Illinois University, Carbondale, IL, USA
| | - Wiley D Jenkins
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - John Schneider
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL, USA; Chicago Center for HIV Elimination, University of Chicago, Chicago, IL, USA
| | - Bruce Link
- Department of Sociology, University of California, Riverside, CA, USA
| | - Mai T Pho
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL, USA
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Friedman SR, Pouget ER, Sandoval M, Nikolopoulos GK, Mateu-Gelabert P, Rossi D, Auerbach JD. New Measures for Research on Men Who Have Sex with Men and for At-Risk Heterosexuals: Tools to Study Links Between Structural Interventions or Large-Scale Social Change and HIV Risk Behaviors, Service Use, and Infection. AIDS Behav 2020; 24:257-273. [PMID: 31313092 DOI: 10.1007/s10461-019-02582-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Large-scale structural interventions and "Big Events" like revolutions, wars and major disasters can affect HIV transmission by changing the sizes of at-risk populations, making high-risk behaviors more or less likely, or changing contexts in which risk occurs. This paper describes new measures to investigate hypothesized pathways that could connect macro-social changes to subsequent HIV transmission. We developed a "menu" of novel scales and indexes on topics including norms about sex and drug injecting under different conditions, experiencing denial of dignity, agreement with cultural themes about what actions are needed for survival or resistance, solidarity and other issues. We interviewed 298 at-risk heterosexuals and 256 men who have sex with men in New York City about these measures and possible validators for them. Most measures showed evidence of criterion validity (absolute magnitude of Pearson's r ≥ 0.20) and reliability (Cronbach's alpha ≥ 0.70). These measures can be (cautiously) used to understand how macro-changes affect HIV and other risk. Many can also be used to understand risk contexts and dynamics in more normal situations. Additional efforts to improve and to replicate the validation of these measures should be conducted.
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Affiliation(s)
- S R Friedman
- Institute for Infectious Disease Research, National Development and Research Institutes, Inc., 71 West 23rd Street, Fourth Floor, New York, NY, 10010, USA.
- Center for Drug Use and HIV Research, New York, NY, USA.
| | - E R Pouget
- Health and Nutrition Sciences, Brooklyn College, Brooklyn, NY, USA
| | - M Sandoval
- Brooklyn Legal Service's Corp A (Group Representation Unit), Brooklyn, NY, USA
| | | | - P Mateu-Gelabert
- Institute for Infectious Disease Research, National Development and Research Institutes, Inc., 71 West 23rd Street, Fourth Floor, New York, NY, 10010, USA
- Center for Drug Use and HIV Research, New York, NY, USA
| | - D Rossi
- University of Buenos Aires and Intercambios Civil Association, Buenos Aires, Argentina
| | - J D Auerbach
- Medicine, University of California San Francisco, San Francisco, CA, USA
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Interpersonal Attacks on the Dignity of Members of HIV Key Populations: A Descriptive and Exploratory Study. AIDS Behav 2017; 21:2561-2578. [PMID: 27752870 DOI: 10.1007/s10461-016-1578-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Attacks on peoples' dignity help to produce and maintain stigmatization and interpersonal hostility. As part of an effort to develop innovative measures of possible pathways between structural interventions or socially-disruptive Big Events and HIV outbreaks, we developed items to measure dignity denial. These measures were administered to 300 people who inject drugs (PWID), 260 high-risk heterosexuals who do not inject drugs, and 191 men who have sex with men who do not inject drugs (MSM). All of the PWID and many of the high risk heterosexuals and MSM were referred to our study in 2012-2015 by a large New York city study that used respondent-driven sampling; the others were recruited by chain-referral. Members of all three key populations experienced attacks on their dignity fairly often and also reported frequently seeing others' dignity being attacked. Relatives are major sources of dignity attacks. MSM were significantly more likely to report having their dignity attacked by police officers than were the other groups. 40 % or more of each key population reported that dignity attacks are followed "sometimes" or more often both by using more drugs and also by using more alcohol. Dignity attacks and their health effects require more research and creative interventions, some of which might take untraditional forms like social movements.
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Pouget ER, Sandoval M, Nikolopoulos GK, Mateu-Gelabert P, Rossi D, Smyrnov P, Jones Y, Friedman SR. Developing Measures of Pathways that May Link Macro Social/Structural Changes with HIV Epidemiology. AIDS Behav 2016; 20:1808-20. [PMID: 26796384 DOI: 10.1007/s10461-016-1291-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Macro-social/structural events ("big events") such as wars, disasters, and large-scale changes in policies can affect HIV transmission by making risk behaviors more or less likely or by changing risk contexts. The purpose of this study was to develop new measures to investigate hypothesized pathways between macro-social changes and HIV transmission. We developed novel scales and indexes focused on topics including norms about sex and drug injecting under different conditions, involvement with social groups, helping others, and experiencing denial of dignity. We collected data from 300 people who inject drugs in New York City during 2012-2013. Most investigational measures showed evidence of validity (Pearson correlations with criterion variables range = 0.12-0.71) and reliability (Cronbach's alpha range = 0.62-0.91). Research is needed in different contexts to evaluate whether these measures can be used to better understand HIV outbreaks and help improve social/structural HIV prevention intervention programs.
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Affiliation(s)
- Enrique R Pouget
- Institute for Infectious Disease Research, National Development and Research Institutes, Inc., 71 West 23rd St., 4th floor, New York, NY, 10010, USA.
| | - Milagros Sandoval
- Institute for Infectious Disease Research, National Development and Research Institutes, Inc., 71 West 23rd St., 4th floor, New York, NY, 10010, USA
| | - Georgios K Nikolopoulos
- Institute for Infectious Disease Research, National Development and Research Institutes, Inc., 71 West 23rd St., 4th floor, New York, NY, 10010, USA
| | - Pedro Mateu-Gelabert
- Institute for Infectious Disease Research, National Development and Research Institutes, Inc., 71 West 23rd St., 4th floor, New York, NY, 10010, USA
| | - Diana Rossi
- Intercambios Civil Association, Corrientes 2548, Piso 2 Oficina D, Buenos Aires, 1046, Argentina
| | - Pavlo Smyrnov
- Alliance for Public Health, 5 Dymytrova Street, Building 10-A, Kiev, 03680, Ukraine
| | - Yolanda Jones
- Institute for Infectious Disease Research, National Development and Research Institutes, Inc., 71 West 23rd St., 4th floor, New York, NY, 10010, USA
| | - Samuel R Friedman
- Institute for Infectious Disease Research, National Development and Research Institutes, Inc., 71 West 23rd St., 4th floor, New York, NY, 10010, USA
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Friedman SR, Tempalski B, Brady JE, West BS, Pouget ER, Williams LD, Des Jarlais DC, Cooper HLF. Income inequality, drug-related arrests, and the health of people who inject drugs: Reflections on seventeen years of research. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 32:11-6. [PMID: 27198555 DOI: 10.1016/j.drugpo.2016.03.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/24/2016] [Accepted: 03/03/2016] [Indexed: 11/24/2022]
Abstract
This paper reviews and then discusses selected findings from a seventeen year study about the population prevalence of people who inject drugs (PWID) and of HIV prevalence and mortality among PWID in 96 large US metropolitan areas. Unlike most research, this study was conducted with the metropolitan area as the level of analysis. It found that metropolitan area measures of income inequality and of structural racism predicted all of these outcomes, and that rates of arrest for heroin and/or cocaine predicted HIV prevalence and mortality but did not predict changes in PWID population prevalence. Income inequality and measures of structural racism were associated with hard drug arrests or other properties of policing. These findings, whose limitations and implications for further research are discussed, suggest that efforts to respond to HIV and to drug injection should include supra-individual efforts to reduce both income inequality and racism. At a time when major social movements in many countries are trying to reduce inequality, racism and oppression (including reforming drug laws), these macro-social issues in public health should be both addressable and a priority in both research and action.
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Affiliation(s)
- Samuel R Friedman
- National Development and Research Institute, Inc., 71 West 23rd Street, 4th Floor, New York, NY 10010, USA.
| | - Barbara Tempalski
- National Development and Research Institute, Inc., 71 West 23rd Street, 4th Floor, New York, NY 10010, USA
| | - Joanne E Brady
- NORC at the University of Chicago, 4350 East-West Hwy, Bethesda, MD 20814 USA
| | - Brooke S West
- Division of Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Drive 0507, La Jolla, CA 92093-0507, USA
| | - Enrique R Pouget
- National Development and Research Institute, Inc., 71 West 23rd Street, 4th Floor, New York, NY 10010, USA
| | - Leslie D Williams
- National Development and Research Institute, Inc., 71 West 23rd Street, 4th Floor, New York, NY 10010, USA
| | - Don C Des Jarlais
- Psychiatry and Preventive Medicine, Icahn School of Medicine at Mount Sinai., 39 Broadway, Suite 530, New York, NY 10006, USA
| | - Hannah L F Cooper
- Rollins School of Public Health at Emory University, 1518 Clifton Road, NE, Atlanta, GA 30322, USA
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Rossi D. This special issue of Substance Use & Misuse explores“Big Events,” Substance Use, and Its Interventions. Introduction. Subst Use Misuse 2015; 50:823-4. [PMID: 26158748 DOI: 10.3109/10826084.2015.1024957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Diana Rossi
- Intercambios Civil Association , Buenos Aires , Argentina
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