Shame anxiety, stigma and clinical encounters

Men and type 2 diabetes: how everyday knowledge remains unshared in gendered medical encounters

PURPOSE

Managing everyday life with type 2 diabetes can be challenging. In particular, men considered vulnerable are often portrayed as lacking self-management. This paper challenges this assumption by highlighting the unheeded knowledge and self-care practices these men develop, and by exploring how these are included in healthcare encounters at an outpatient clinic in Denmark.

METHODS

Data were collected through observations of clinical practice and subsequent interviews with 12 men who have type 2 diabetes. A thematic analysis was conducted to explore their daily experiences of managing chronic illness and their encounters with healthcare professionals.

RESULTS

Men considered vulnerable manifest important knowledge and strategies in managing type 2 diabetes in their daily lives, often perceiving the illness as barely present. Their encounters with healthcare professionals, particularly females, often draw on repertoires from previous experiences with (often female) care professionals and seem to follow a certain script for (female) carers encountering disadvantaged (male) care recipients. These dynamics frequently overlook the men's lived experiences and self-management knowledge.

CONCLUSION

Men considered vulnerable develop important coping strategies and knowledge for managing type 2 diabetes in their everyday lives. However, their encounters with health professionals often perpetuate gendered assumptions and exclusion of their everyday experiences and knowledge.

Dismissive medicine and gaslighting of patients by physicians - A bioethics lens

OBJECTIVES

This Discussion paper seeks to raise awareness of the phenomena of dismissive medicine (DM) and medical gaslighting (MG) and their underlying threats to principles of Bioethics. DM refers to mistreatment and negative patient-physician interactions. In most studies on DM, patients perceived physicians as invalidating their illness, as uniformed, as blaming and stigmatizing them, misunderstanding their condition, insensitive, rushing the visit, refusing to discuss pain, rude, and failing to maintain eye contact, listen, and to provide appropriate information about causes and treatments. A special case of DM is MG, referring to the experience of patients when their medical complaints and suffering are discounted, doubted, questioned, second guessed, or denied by physicians causing patients self-doubts. DM and MG may occur, at times, unintentionally Durbhakula and Fortin [1] and Fielding-Singh and Dmowska [2], resulting in severe ramifications. Surprisingly, existing reports focused on the clinical, economic, psychological, and emotional ramifications of DM and MG (Braeuninger-Weimer et al., 2019; Burke, 2019; Street et al., 2019; Merone et al., 2022; Claréus and Renström, 2019; Sheehan, 2020; Turan et al., 2019; Penner and Paul, 2017; Au et al., 2022; Dolezal, 2022; Shapiro and Hayburn, 2024; Fuss et al., 2024; Hunt, 2022) [3-15], rather than on the infringement of bioethics, which is the focus of this Discussion paper.

CONCLUSIONS

DM and MG not only cause patients to feel stigma, prejudice, shame, and blame, and develop fear of seeking clinical help but also, constitute infringements of beneficence, non-malfeasance, respect for patient right of autonomy, and distributive justice in patient care. This Discussion paper calls for more education about the implicit ethical aspects of these phenomena and policy modifications to efface DM and MG.

Gaslighting of Inpatients-A threat to nursing care and a violation of relational autonomy

Background Medical gaslighting refers to the mistreatment that patients experience following interactions with clinicians when their medical complaints and suffering are discounted, doubted, questioned, second-guessed, or denied, resulting in self-doubts of patients and psychological ramifications. This research focuses on the ethical aspects of medical gaslighting among hospitalized patients by nurses.Research QuestionWhat are the nursing care and nursing ethics perspectives concerning medical gaslighting? Research DesignA narrative review.Research MethodInterpretation of two narrative interviews with each participant through the lenses of nursing ethics.Participants14 hospitalized patients, males and females, ages 30-81, from the majority group in the population.ContextLengthy hospitalizations.Ethical considerationsEthical approval was granted; all participants signed an informed consent form for participation and publication.FindingsPatient experiences demonstrate medical gaslighting by nurses, violating relational autonomy and resulting in delayed care.DiscussionMedical gaslighting contradicts ethics of care, the professional values of nursing, and patient-centered care constituting obstacles to respectful patient-nurse relationships and to relational autonomy.ConclusionsMedical gaslighting is a profoundly concerning ethical phenomenon that adversely affects patient well-being and trust in nursing as a significant profession in a just society.

Self-blaming as a barrier to lung cancer screening and smoking cessation programs in Italy. A qualitative study

BACKGROUND

Lung cancer screening (LCS) combined with smoking cessation programs is a critical strategy for reducing lung cancer mortality. Understanding the perspectives of cigarette users and former ones on these interventions is essential for enhancing their acceptability and effectiveness. This study aimed to explore, in Italy, the perceptions and experiences of individuals eligible for LCS within the context of a smoking cessation program.

METHODS AND FINDINGS

This multicenter qualitative study was conducted in two Italian regions as part of a larger project the Italian League against Cancer promoted. Using purposive sampling, we included (a) cigarette users and former ones who participated in an Italian trial, ITALUNG study, and (b) cigarette users who had been offered individual or group smoking cessation interventions and were theoretically eligible for screening in the following years (aged 50-70, ≥15 pack-years). Data were collected through open-ended semi-structured interviews and focus group meetings and analyzed using reflexive thematic analysis. The data analysis yielded six themes covering participants' views on the interactions between the two types of interventions (screening and smoking cessation program). Across their data, we generated the following themes: (i) depreciation and fatalism toward the risk of smoking, (ii) self-blaming and ethicality, (iii) ambivalent impact of the screening on smoking, (iv) LCS-related information and concerns, (v) teachable and motivating moments, and (vi) non-stigmatizing communication and testimony by professionals.

CONCLUSIONS

Our study underscores the importance of avoiding stigma and respecting the dignity of cigarette users in implementing LCS and smoking cessation programs. Clear communication and supportive interactions with healthcare providers are crucial for enhancing the acceptability and effectiveness of these interventions. Future research should focus on quantifying these findings and exploring additional factors influencing the acceptability and effectiveness of combined LCS and smoking cessation programs.

Shame-Sensitive Public Health

In this article, we argue that shaming interventions and messages during Covid-19 have drawn the relationship between public health and shame into a heightened state of contention, offering us a valuable opportunity to reconsider shame as a desired outcome of public health work, and to push back against the logics of individual responsibility and blame for illness and disease on which it sits. We begin by defining shame and demonstrating how it is conceptually and practically distinct from stigma. We then set out evidence on the consequences of shame for social and relational health outcomes and assess the past and present dimensions of shame in the context of the Covid-19 pandemic, primarily through a corpus of international news stories on the shaming of people perceived to have transgressed public health directions or advice. Following a brief note on shame (and policymaking) in a cultural context, we turn to the concept and practice of 'shame-sensitivity' in order to theorise a set of practical and adaptable principles that could be used to assist policymakers in short- and medium-term decision-making on urgent, tenacious, and emerging issues within public health. Finally, we consider the longer consequences of pandemic shame, making a wider case for the acknowledgement of the emotion as a key determinant of health.

From Psyche to Skin: A Call for Interdisciplinary Care in the Management of Psychodermatologic Conditions

Despite increasing academic discourse surrounding psychodermatology, few dermatologists or psychiatrists demonstrate a clear understanding of the field. Barriers to physician awareness are double-edged, stemming from both inadequate educational opportunities and patient non-disclosure of psychodermatologic symptoms during clinical encounters. It is crucial that medical practitioners, especially in the field of dermatology, become accustomed to recognizing, diagnosing, and treating psychocutaneous disorders, which disproportionately affect members of historically marginalized populations. In this commentary, we propose recommendations for pedagogic supplements to be implemented throughout medical, post-graduate, and post-residency education to build familiarity with this subdiscipline and confidence in managing its associated conditions. In particular, we endorse the integration of components of psychiatry education into dermatology residency training and current practice, as skin symptoms tend to be more openly disclosed than mental health struggles, so dermatologists are often the first physicians to encounter many of these conditions. We also advocate for interdisciplinary collaboration to bridge the gap between the uniformity of standard specialty training and the complexity of psychocutaneous disease.

Mental Health Treatment Access: Experience, Hypotheticals, and Public Opinion

Policy Points Policymakers should consider both material (e.g., cost) and attitudinal (e.g., skepticism) barriers to mental health treatment access. Public support for government action on mental health is high but varies based on experience-based and hypothetical beliefs about barriers to treatment. Appeals to personal experience and perspective-taking may be successful in building support for government action on mental health.

CONTEXT

Mental health problems represent a major public health issue for the United States, and access to mental health treatment is both inadequate and unevenly distributed. There is a strong justification for government action on mental health treatment, but it is unclear whether there is a political constituency for such action. Existing work suggests that stigma and othering of people with mental illnesses contributes to reduced support for intervention. I expand on the existing literature by focusing on mental health as an issue that may apply to Americans' own lives rather than only to a stigmatized outgroup.

METHODS

Using original questions on a nationally representative 2023 survey of 1,000 American adults, I measured agreement with statements about barriers to mental health treatment access that respondents have experienced or, if they have not sought treatment, their hypothetical assessment of these barriers. I also measured their support for statements in favor of change to address mental health. I analyzed the demographic and political correlates of agreement with the barrier statements and used regressions to examine their possible causal effect on support for change.

FINDINGS

Agreement with statements about access barriers follows expected patterns in some cases (e.g., socioeconomic status) but not in others (e.g., race/ethnicity). I also documented a notable partisan and ideological divide in these experiences and beliefs. I found that Americans who agreed that material factors are a barrier to access were more supportive of action on mental health, whereas those who agreed with statements suggesting discomfort or skepticism were less supportive.

CONCLUSIONS

These findings suggest that personal experience and perspective-taking should be integrated into the study of public opinion on mental health, complementing existing work on stigma and othering. Appeals to experience and perspective-taking may be a successful strategy for building public support for action on mental health.

Internalized Shame in Treatment-Seeking Adults with Obesity Class II-III and Its Association with Quality of Life, Body Image, and Self-Esteem

INTRODUCTION

Health-related quality of life (HRQoL) may be impaired in individuals living with obesity, possibly due to exposure to obesity-related stigma which may in turn activate shame. Few studies have been conducted on shame in relation to obesity and its potential association with other constructs such as HRQoL, self-esteem, and body image. In this study, internalized shame and the potential association with HRQoL, self-esteem, and body image were investigated in treatment-seeking patients with obesity class II-III.

METHODS

In total, 228 patients referred for obesity treatment at a tertiary clinic in Sweden participated in the study. The cohort was stratified into two groups using a clinical cutoff (≥50) indicating pathological levels of shame as reported on the Internalized Shame Scale (ISS): a high shame group (HSG) and low shame group (LSG).

RESULTS

The mean ISS score for the overall cohort was 41.6, with a mean of 28.1 for the LSG and 66.5 for the HSG. Compared to the LSG, the HSG reported a lower quality of life in seven of eight HRQoL domains as well as a lower obesity-specific health-related quality of life. Furthermore, a higher shame score was associated with poorer body image and lower self-esteem.

CONCLUSION

Taken together, these findings indicate that a substantial number of patients with obesity report high internalized shame and that these individuals could benefit from extra support in treatment settings.

Motivational Interviewing (MI) in Obesity Care: Cultivating Person-Centered and Supportive Clinical Conversations to Reduce Stigma: A Narrative Review

Background

Patients perceive high levels of weight prejudice, stigma, and discrimination within health systems, affecting their ability to manage their obesity and related chronic conditions. Scientific and patient obesity associations worldwide have prioritized the reduction of weight stigma to improve patient experiences in health systems and overall health outcomes. Since a significant proportion of the population is now living with multiple chronic diseases related to obesity, healthcare systems must shift toward multi-disease management frameworks incorporating person-centered and non-stigmatizing clinical conversations. Motivational Interviewing (MI) has the potential to transform clinical interactions by using non-stigmatizing language, communication, and practices. Studies using MI in obesity management have solely focused on weight loss outcomes, while other patient experience related outcomes would also be relevant to evaluate.

Methods

A narrative review was undertaken to critically analyze the potential impact of MI on obesity and chronic disease management practices and experiences.

Findings

An analysis and contextualization of the MI theoretical framework for obesity management, based on the philosophy of motivational spirit, was reviewed, assessing micro skills or strategies.

Conclusion

MI may assist healthcare professionals conduct non-stigmatizing clinical conversations in accordance with basic principles of collaborative therapeutic alliances. A proposal for research considerations that can help illuminate the potential for of MI in obesity management is also outlined.

Why Teens Don't Talk: Understanding the Role of Stigma Within Barriers to Help Seeking

The stigma of mental illness, among a larger set of barriers to help seeking, has been understudied among teens. These barriers and the sources of support were examined through an online survey with 1,428 U.S. 13- to 17-year-olds. Data were analyzed using Q, with indexing and Z tests calculated for significant group differences. Parents were cited as the top support source for depression compared with mental health professionals. Nonstigma barriers were the top barriers for teens, including discomfort with difficult emotions and being misunderstood when reaching out for support. Stigma barriers were significantly higher for Hispanic and LGBTQ+ teens, and stigma-adjacent barriers were significantly higher among Black/African American teens. Results are discussed in terms of the differential support that teens need to navigate emotional challenges and for further understanding barriers to help seeking that are not weighed heavily by stigma, as in past studies.

Tooth shame - An ethnographic study of the choreographies of tooth shame in Danish elderly care

This study suggests the term tooth shame and explores it as a phenomenon encompassing deep entanglements between emotional experiences, social interactions, and care work practices. Drawing on shame research concerning the body, health, and class, juxtaposed with odontological research on the social implications of oral health issues, it investigates how tooth shame appears in Danish elderly care. In Denmark, oral health is notably impaired among older people depending on professional care, with significant repercussions for general health and social life. The study stems from the Lifelong Oral Health project, which identifies barriers to oral health and examines the potential to improve it in Danish elderly care. It is based on ethnographic fieldwork in nursing homes, home care units, and a rehabilitation center in two Danish municipalities. As self-derogative statements and self-limiting behaviors regarding oral health issues stood out as a general finding in interviews with older people, the focus on tooth shame emerged from this fieldwork. The study contributes to recent shame discussions with a social-material understanding of tooth shame, emphasizing that it is more than an individual feature. It is a collectively distributed phenomenon that expands among people and situations, and that interferes with vital caring practices. The study suggests that tooth shame appears through the performance of tooth shame choreographies, highlighting its implications in a socio-material setting. First, it demonstrates that tooth shame can make older people adapt to oral health issues, for example, by avoiding social interactions, dental care, and oral treatments. Second, it identifies tooth shame as a collectively distributed and expanding phenomenon, as it draws, for example, care workers into sensitive shame situations. Third, it explores how tooth shame interferes with daily dental care practices, professional considerations, and ethical dilemmas within elderly care systems.

REVIVE Is an Evidence-Based Approach for Nurses to Universally Apply Trauma-Informed Care in Maternity Settings

The principles of trauma-informed care-safety, compassion, collaboration, communication, autonomy, and empowerment-are also the domains most vulnerable to implicit bias and most cited in adverse outcomes in maternal health. Perinatal nurses can practice trauma-informed care universally and thereby foster and advance person-centered care for all individuals with respect to race, ethnicity, religion, or lived experiences. In this article, we present evidence-based nursing interventions, collectively called REVIVE, that are known to promote principles of trauma-informed care. Taken together, the REVIVE interventions may improve health outcomes and reduce disparities in maternal health outcomes because they are proactive nursing interventions independent of implicit bias. REVIVE is described here and intended for use by individual nurses or health care teams to implement and evaluate in different maternity settings.

Structural Equation Modeling of Childhood Trauma and Self-Stigma in Adult Inpatients with Borderline Personality Disorder

Purpose

Child abuse and trauma are significant risk factors in the etiology of borderline personality disorder (BPD). Apart from affecting the risk of developing BPD, adverse childhood experiences seem to increase its symptoms and related disability. Self-stigma presents another common issue with equally prominent consequences for mental health. Despite being theoretically linked, the connections among childhood trauma, self-stigma, and mental health have not been explored in patients with BPD. This study aimed to provide first insights into this understudied topic.

Patients and Methods

This cross-sectional study included 283 inpatients diagnosed with BPD participating in a residential transdiagnostic psychotherapeutic program. The patients completed several measurements - the Internalized Stigma of Mental Illness Scale, the Childhood Trauma Questionnaire - Short Form, the Clinical Global Impression - Severity, the Beck Depression Inventory-II, the Beck Anxiety Inventory, the Dissociative Experiences Scale, the Sheehan Disability Scale, and a demographic questionnaire. The data was statistically analyzed using IBM SPSS and AMOS 26 programs, and bivariate correlation tests and structural equation modeling explored the hypotheses.

Results

Retrospectively reported childhood trauma positively correlated with current self-stigma. Both childhood trauma and self-stigma were also positively related to several indicators of general psychopathology and disability. The significance of these connections was subsequently confirmed by structural equation modeling, where self-stigma acted as a partial mediator of childhood trauma, general psychopathology, and disability.

Conclusion

Self-stigma significantly mediates the relationship between childhood trauma and selected mental health symptoms among adult patients diagnosed with BPD. Longitudinal studies are necessary to explore the causality of the findings. Therapeutic and societal efforts to tackle childhood trauma or self-stigma might benefit from reflecting its broader psychosocial context.

Making sense of drug use and dependence-A scoping review of mass media interventions intended to reduce stigma towards people who use drugs

BACKGROUND

People who use drugs face entrenched stigma, which fosters shame, restricts service access, and exacerbates inequalities. The use of mass media in anti-stigma interventions offers an opportunity to challenge stigmatising attitudes at scale. There are, however, inconsistencies in messaging approaches used in mass media anti-stigma interventions, and how authors conceptualise and measure 'stigma'.

METHODS

This scoping review maps literature on the development and/or evaluation of mass media interventions intended to reduce stigma towards people who use drugs. We systematically searched seven databases for reports about: (i) people who use drugs, (ii) stigma, (iii) mass media. We charted data about intervention (i) subjects and recipients, (ii) format, (iii) authors, (iv) content; and (v) conceptualisation and measurement of stigma. We narratively synthesised findings with qualitative content analyses.

RESULTS

From 14,256 records, we included 49 reports about 35 interventions. 25/35 were from the last five years and 19/35 were from the United States. Intended recipients included the public and/or specified sub-populations, often including healthcare workers. Most interventions were intended to reduce stigma towards people with patterns of drug use perceived to be problematic, as opposed to people who use drugs in general. Interventions ranged from single pieces of media to complex multi-format campaigns. People who use(d) drugs contributed to 22/35 interventions. Professionals working in medical disciplines co-authored 29/35 interventions. Intervention content often had a medical focus, describing dependence as a 'disease' or medical issue, and emphasised the benefits of recovery. Other interventions, however, criticised medical framings. In some interventions drug use and people who use drugs were described in markedly negative terms. 'Stigma' was often under-theorised, and measurement approaches were inconsistent, with 42 instruments used to measure phenomena associated with stigma across 19 quantitative evaluations.

CONCLUSION

We found inconsistencies in approaches to reduce and measure stigma, potentially reflecting different motivations for intervention development. The primary motivation of many interventions was seemingly to promote drug service engagement and recovery.

Shame in patient-health professional encounters: A scoping review

Shame can arise during patient-health professional encounters when discussing traumatising and stigmatising topics and can contribute to negative patient outcomes. This review aims to summarise what is known regarding shame in patient-health professional encounters. We conducted a scoping review using Levac and colleagues' approach and reported the findings using the PRISMA Extension for Scoping Reviews. We searched four databases (CINAHL, PsychINFO, PubMed and SocINDEX) for empirical studies that involved shame in patient-health professional encounters contextualised by trauma or stigma and were published in English. We categorised what is known regarding shame in empirical studies using inductive content analysis. We also collected stakeholders' perspectives on the review findings through an online survey. Our initial search yielded 3658 articles, of which 37 were included. We summarised the literature into four categories: (1) What health professionals say they do in patient-health professional encounters, (2) What health professionals think patients feel in patient-health professional encounters, (3) Patients' descriptions of their own shame during patient-health professional encounters and (4) Health professionals' descriptions of their own shame during patient-health professional encounters. Shame can arise in a variety of circumstances during patient-health professional encounters. More research is needed to identify what specific communication strategies used by health professionals during patient-health professional encounters contribute to or avoid patient shame.

Understanding stigma in the context of help-seeking for eating disorders

BACKGROUND

Stigma is a complex construct and its association with help-seeking among those experiencing eating disorders is not well understood. Rates of help-seeking are low for those with eating disorder symptoms and, therefore, determining the role of stigma and shame in this relationship is needed to help inform effective awareness campaigns aimed at improving prognostic outcomes. The current study examined the associations between perceived stigma, self-stigma, shame, and help-seeking behaviour in a community sample of individuals with elevated eating disorder symptoms.

METHODS

Participants completed an online survey that included measures of stigma and shame as perceived barriers to help-seeking for individuals with eating disorders. Those with elevated eating disorder symptoms and high clinical impairment were included in the study (N = 333).

RESULTS

Using binary logistic regression models controlling for age and gender, results showed that perceived stigma, self-stigma, and shame predicted 64% of help-seeking behaviour (p = .005). The only significant unique predictor of formal help-seeking was "Being concerned that other people believe eating disorders are not real illnesses". No other stigma or shame items were found to significantly predict help-seeking.

CONCLUSIONS

The present findings suggest that while stigma plays an important role in help-seeking, it might not be the primary reason preventing individuals with eating disorders from accessing care. The field is encouraged to investigate these factors to promote help-seeking effectively.

Shame, health literacy and consent

This paper is particularly concerned with shame, sometimes considered the 'master emotion', and its possible role in affecting the consent process, specifically where that shame relates to the issue of diminished health literacy. We suggest that the absence of exploration of affective issues in general during the consent process is problematic, as emotions commonly impact upon our decision-making process. Experiencing shame in the healthcare environment can have a significant influence on choices related to health and healthcare, and may lead to discussions of possibilities and alternatives being closed off. In the case of impaired health literacy we suggest that it obstructs the narrowing of the epistemic gap between clinician and patient normally achieved through communication and information provision. Health literacy shame prevents acknowledgement of this barrier. The consequence is that it may render consent less effective than it otherwise might have been in protecting the person's autonomy. We propose that the absence of consideration of health literacy shame during the consent process diminishes the possibility of the patient exerting full control over their choices, and thus bodily integrity.

Stigmatisation in medical encounters for persistent physical symptoms/functional disorders: Scoping review and thematic synthesis

OBJECTIVE

To conduct a scoping review of stigma in medical encounters for persistent physical symptoms and functional disorders (PPS/FD). Stigma is a social attribute that links a person to an undesirable characteristic. It has been extensively studied in relation to mental illness but less so in relation to PPS/FD.

METHODS

We followed PRISMA-ScR reporting guidelines for scoping reviews. Searches for were designed using the SPIDER tool. We used descriptive and thematic analysis.

RESULTS

The searches identified 68 articles, of which 32 were eligible for inclusion. 31 out of the 32 studies used a qualitative methodology. 8 studies used an explicit definition of stigma, of which 6 used the Goffman (1963) definition. Only 2 studies directly examined clinical consultations, the remainder relied on recalled accounts by patients or professionals. Descriptive analysis identified the focus of the studies included: patient-physician interaction (n = 13); health care professionals' perceptions (n = 7); experiences of illness/stigma (n = 6); broader meaning of illness (n = 3); and patients' experiences of stigma in health care consultations (n = 3).

CONCLUSION

Patients experience stigmatisation in consultations for a wide range of PPS/FD. This suggests the presence of structural stigmatisation.

PRACTICE IMPLICATIONS

There is a need for effective stigma reduction strategies in consultations about persistent physical symptoms.

A qualitative study of perceived barriers and facilitators to interrupting sedentary behavior among adults living with obesity

Introduction

Both obesity and sedentary behavior (SB) are associated with negative health consequences including cardiovascular disease, diabetes, certain cancers and all-cause mortality. To date, perceived barriers and facilitators to interrupting SB in adults living with obesity have not been identified.

Objective

This study aimed to identify these perceived barriers and facilitators by conducting a behavioral analysis underpinned by the theoretical domains framework (TDF) and the Capability, Opportunity, Motivation-Behavior (COM-B) model to enhance knowledge and inform future intervention development.

Methods

A purposive and snowball sample (N = 21) of adults living with obesity took part in semi-structured interviews, guided by the TDF, to investigate perceived barriers or facilitators to interrupt SB. Transcribed interviews were inductively coded using reflexive thematic analysis. Key themes and subthemes were generated by grouping similar and recurring codes. Finally, subthemes were mapped to the TDF and COM-B.

Results

Five key themes were identified, which influence SB across all domains of living. These relate to (i) physical and mental wellbeing; (ii) motivational readiness; (iii) roles, responsibilities and support; (iv) weight bias and stigma; and (v) the environment. These themes were then deductively mapped to all 14 TDF domains and all six of the COM-B constructs.

Conclusion

A complex interplay of individual, societal and policy factors contributes to the development and habituation of SB patterns in adults living with obesity. Factors identified in this study could assist in the development of interventions, strategies and policies designed to interrupt or reduce sedentary behavior in this population.

The relationship between HIV-related stigma and quality of life among HIV infected outpatients: A cross-sectional study in Vietnam

Background

The impact of stigma on individuals with HIV remains a significant challenge, causing feelings of worthlessness, shame, and emotional distress. This study aimed to examine the relationship between HIV-related stigma and quality of life (QOL) among HIV-infected outpatients initiating antiretroviral therapy (ART) in Vietnam.

Design and methods

This was a cross-sectional study which conducted at Vinh General Hospital, Nghe An Province, involved 323 HIV-infected outpatients. Participants were surveyed between October 2020 and October 2021. The study collected data through structured interviews, assessing socio-demographic factors, HIV stigma, and QOL.

Results

The result showed that HIV-infected outpatients experiencing higher stigma showed poorer QOL across various domains. The negative impact of stigma was particularly evident in domains related to physical health, psychological well-being, and spirituality. Participants who were married, had children, consumed alcohol, had comorbidities (particularly hepatitis B/C), and lacked a history of drug use reported varying levels of correlation with QOL domains and stigma.

Conclusions

By identifying the intricate connections between stigma and QOL, the study provides valuable insights for designing comprehensive interventions that prioritize the well-being of HIV infected outpatients.

Patient experiences of a 10-weeks weight-neutral treatment program for clinical binge eating disorder in a higher weight population

BACKGROUND

Weight based stigma might drive the development of both higher weight and binge eating disorder (BED). To improve treatment and outcomes, a deeper understanding of how stigma and shame are correlated in clinical encounters is needed. The current study was designed to gain insight into how participating in a 10-weeks weight-neutral treatment program for patients with binge eating disorder and higher weight was experienced.

METHODS

Semi-structured interviews were conducted with 10 patients who had completed the BED treatment. The intervention was group based, addressing stigma and shame, using models of attachment and affect regulation in the presentation of BED. Interviews were analyzed guided by van Manen's hermeneutic-phenomenological approach.

RESULTS

A profound feeling of inferiority due to weight stigma and adverse childhood experiences appeared to have kept the participants stuck in a shame driven carousel  of dieting, weight loss, bingeing, and weight regain. Participants and health care professionals' mutual acknowledgement of driving elements of binge eating appeared to support participants feeling more equal. Feeling equal was described as facilitating increased awareness and tolerance of bodily sensations and emotions, and a deeper understanding and self-caring attitude towards themselves. Feeling less shame was described as important for self-disclosure in family relationships, leading to increased understanding and support from others. Simultaneously, unchanged stigmatizing surroundings were described to relate to challenges with eating patterns and weight after end of treatment.

CONCLUSION

Our findings indicate that relational symmetry, by patients experienced as being met with recognition, compassionate acceptance, and mutual investigation of subjective experience, can contribute to reduction of weight stigma and shame, and the burdensome notion of inferiority experienced by the participants in everyday life, hence improving treatment outcomes. Trail registration The study was approved and registered by the Data Access Committee at Nord-Trøndelag Hospital Trust August 8th, 2019, registration number 2019_2335.

The promises and pitfalls of seizure phenomenology

The typical adult patient presenting with a first seizure has a normal clinical examination, uninformative investigations, and often has no witness to their episode. The assessing clinician, therefore, has one primary source of information to guide their assessment; the patient's experience. However, seizure phenomenology - the subjective seizure experience - has received relatively less attention by researchers than objective semiology or investigations. This essay reviews the clinical importance of seizure phenomenology, and the challenges clinicians face in eliciting accurate and clinically relevant descriptions of ictal experience. I conclude by discussing tools that clinicians may use to support the clinical application of seizure phenomenology, and exploring the subjectivity of epilepsy more broadly.

Identifying Variables Associated with Menopause-Related Shame and Stigma: Results from a National Survey Study

Background: Despite the significance of menopause as a natural biological milestone experienced by approximately half the population, few studies have evaluated factors associated with menopause-related shame and stigma. Given previous research indicating increased shame and stigma are associated with negative outcomes that directly impact health (e.g., reduced access to health care), it is critical to identify variables associated with menopause-related shame and stigma. Materials and Methods: As part of a larger, national survey, 214 perimenopausal (n = 111) and postmenopausal (n = 103) individuals completed self-report questionnaires assessing demographics and menopause-related symptoms, shame, and stigma. Regression analyses examined variables associated with shame and stigma. Results: Over a third of respondents reported feeling shame related to their menopause-related symptoms (37.4%), while the majority of respondents reported feeling stigma associated with symptoms (82.7%). In addition, most respondents endorsed talking about their symptoms with friends, family, partners, or doctors (80.8%), and felt that their peers might experience the same symptoms (93.9%). Regression analyses identified several significant predictor variables; in particular, more severe psychosocial and urogenital symptoms, higher education level, and younger age were significantly associated with greater odds of reporting shame and stigma. Conclusions: Overall, findings suggest that even though menopausal individuals report feeling their symptoms are similar to their peers, shame and stigma are significantly associated with these symptoms, which may be impacted by symptom severity and socioeconomic factors. Results suggest that younger individuals (i.e., those just entering perimenopause) with more education may be more likely to feel shame and stigma, which could inform interventional strategies and improve clinical outcomes.

A Comprehensive Review of Motherhood and Mental Health: Postpartum Mood Disorders in Focus

The journey of motherhood encompasses a profound array of emotions, experiences, and challenges that extend beyond the surface of joy and elation. This review delves into the crucial yet often underexplored realm of postpartum mood disorders, aiming to illuminate their significance and foster understanding. Postpartum mood disorders, including postpartum depression, anxiety disorders, and psychosis, impact the mental well-being of mothers during a pivotal phase of their lives. Through a comprehensive exploration, this review elucidates the various dimensions of these disorders, from their definitions and classifications to their prevalence and impact on both mothers and families. Identifying and diagnosing postpartum mood disorders is discussed in detail, shedding light on the emotional, cognitive, and physical symptoms that warrant attention. Screening and assessment tools are highlighted as essential instruments for early detection, while challenges in diagnosis, including the overlap with typical postpartum experiences and the influence of stigma, are explored. The review further delves into treatment and intervention, underscoring the importance of psychotherapy, pharmacological interventions, and individualised treatment plans. The roles of healthcare providers and mental health professionals in offering support and guidance are emphasised, emphasising the significance of a collaborative approach. Cultural and societal influences are crucial in shaping perceptions of motherhood and mental health. The review explores how these influences can create barriers to seeking help and highlights the importance of destigmatising postpartum mood disorders. It underscores the urgency of raising awareness and fostering a supportive environment that empowers mothers to seek assistance without fear of judgment. Looking toward the future, the review points to potential research directions, such as advances in understanding hormonal influences and exploring the long-term effects on maternal mental health. The overarching call to action resonates - increased awareness, support, and dismantling stigma are imperative. A hopeful vision is presented: a future where all mothers receive appropriate mental health care, no mother stands alone in her motherhood journey, and societal understanding and compassion thrive.

Associations Between Cognitive Impairment Severity and Barriers to Healthcare Engagement Among Older Adults

Objectives: To assess whether older adults with a cognitive impairment were more likely to report challenges interacting with medical providers, or to avoid needed medical care. Methods: Data for this exploratory, cross-sectional analysis were from older adults (N = 493) ages 60-82 participating in the "LitCog" cohort study. Multivariable generalized linear models compared cognitive impairment (none, mild, moderate, severe) with validated measures of healthcare engagement. Results: A moderate cognitive impairment was associated with delays in medical care due to embarrassment (RR 5.34.95% CI 1.30-22.0) and discomfort asking the doctor questions (RR 4.07, 95% CI 1.00-16.5). Conclusions: Intermediate cognitive deficits, such as with mild cognitive impairment (MCI) or mild dementias, may impact meaningful engagement with healthcare systems, potentially affecting timely detection and appropriate management of cognitive concerns and other chronic medical conditions. More research is needed to understand mechanisms underlying this relationship.

Introducing the Neuroplastic Narrative: a non-pathologizing biological foundation for trauma-informed and adverse childhood experience aware approaches

Most people accessing mental health services have adverse childhood experiences (ACEs) and/or histories of complex trauma. In recognition of this, there are calls to move away from medical model approaches and move toward trauma-informed approaches which privilege the impact of life experience over underlying pathology in the etiology of emotional and psychological suffering. Trauma-informed approaches lack a biological narrative linking trauma and adversity to later suffering. In its absence, this suffering is diagnosed and treated as a mental illness. This study articulates the Neuroplastic Narrative, a neuroecological theory that fills this gap, conceptualizing emotional and psychological suffering as the cost of surviving and adapting to the impinging environments of trauma and adversity. The Neuroplastic Narrative privileges lived experience and recognizes that our experiences become embedded in our biology through evolved mechanisms that ultimately act to preserve survival in the service of reproduction. Neuroplasticity refers to the capacity of neural systems to adapt and change. Our many evolved neuroplastic mechanisms including epigenetics, neurogenesis, synaptic plasticity, and white matter plasticity allow us to learn from, and adapt to, past experiences. This learning and adaption in turn allows us to better anticipate and physiologically prepare for future experiences that (nature assumes) are likely to occur, based on past experiences. However, neuroplastic mechanisms cannot discriminate between experiences; they function to embed experience regardless of the quality of that experience, generating vicious or virtuous cycles of psychobiological anticipation, to help us survive or thrive in futures that resemble our privileged or traumatic pasts. The etiology of suffering that arises from this process is not a pathology (a healthy brain is a brain that can adapt to experience) but is the evolutionary cost of surviving traumatizing environments. Misidentifying this suffering as a pathology and responding with diagnosis and medication is not trauma-informed and may cause iatrogenic harm, in part through perpetuating stigma and exacerbating the shame which attends complex trauma and ACEs. As an alternative, this study introduces the Neuroplastic Narrative, which is situated within an evolutionary framework. The Neuroplastic Narrative complements both Life History and Attachment Theory and provides a non-pathologizing, biological foundation for trauma-informed and Adverse Childhood Experience aware approaches.

Psychometric properties of an Arabic translation of the external and internal shame scale (EISS)

BACKGROUND

The concept of shame in Arab societies displays multiple differences when compared to Western societies in terms of nature, sources, types, and correlates. Surprisingly, we could not find any study investigating this increasingly important construct in Arab countries or the broad Arabic-speaking communities. This may likely be due to the lack of valid instruments assessing shame in the Arabic language. To address this major gap and contribute to the international literature, we sought to examine the psychometric properties of an Arabic translation of the External and Internal Shame Scale (EISS) among a community sample of Arabic-speaking adults from Lebanon.

METHODS

An online survey was conducted among Lebanese adults between July and August 2022. A total of 570 Lebanese adults completed the EISS, as well as Depression Anxiety Stress Scales, Other as shamer scale, and the Standardized Stigmatization Questionnaire. Exploratory-to-confirmatory (EFA-CFA) factor analyses were conducted.

RESULTS

Exploratory and confirmatory factor analyses supported a unidimensional model of EISS scores, with all eight items retained. Scores achieved scalar invariance across gender, with no significant difference reported between females and males. EISS scores were found to have adequate composite reliability (McDonald's ω = 0.88 for the total score); as well as adequate patterns of correlations with depression, anxiety and stress symptoms, as well as stigmatization scores. Finally, our analyses provide support to the concurrent validity of the Arabic version of the scale, by showing that the EISS total scores strongly correlated with the external shame measure "other as shamer".

CONCLUSION

Although further validations are necessary before our findings could be generalized, we preliminarily suggest that this is a short, easy-to-use, self-report scale that enables a reliable and valid measure of the shame construct among Arabic-speaking people.

Patientology revisited: Toward tailored care pathways

BACKGROUND

Concepts such as patient-centred care, patient empowerment and patient participation have challenged our understanding of what it means to be a patient and what role patients play in care pathways. Consequently, patientology as the medical sociological and anthropological study of patients is currently being reconceptualized through perspectives of health as individualized and privatized capital.

AIMS

This article explores the potential of such a patientological perspective to enhance our understanding of and tailor care pathways. Particularly, we aim to investigate how such a perspective can contribute to tailoring care pathways to the capacities of individual patients and their relatives.

MATERIALS & METHODS

We elaborate on an emerging health capital-theoretic model for patientology and study its potential for optimizing care pathways through two distinct cases of care contexts: communicative challenges in the context of integrative primary care for vulnerable chronically ill multi-morbid patients and the potential of parent involvement in the acute hospitalization of children suspected to be affected by multisystem inflammatory syndrome in children.

RESULTS

Our results shed light on the importance of cultural and social capital of patients and their relatives in the design of effective tailored care pathways. We find that a lack of cultural and social capital presents a significant barrier to effective communication between patients and the healthcare professionals involved in their care pathways. We also find that understanding the cultural and social capital of relatives provides an entry point to their effective involvement in the care pathways of their children.

DISCUSSION & CONCLUSION

The implications of these findings extend beyond the concrete care contexts studied. This article contributes to our understanding of care pathways through a perspective of health inequalities being based on differences in health capital and demonstrates how the health capital-theoretic patientology model facilitates the systematic development of guidelines for healthcare professionals to assess patients' resources and tailor their care pathways accordingly.

The effects of shame and stigma on patient care

Stigma in healthcare has been associated with a range of negative outcomes, such as delays in seeking treatment, avoiding clinical encounters and mental distress. This editorial discusses the experience of stigma and argues that understanding shame anxiety and adopting ‘shame-sensitive’ practice is beneficial in healthcare.

The Horizons of Chronic Shame

Experiences of shame are not always discrete, but can be recurrent, persistent or enduring. To use the feminist phenomenologist Sandra Lee Bartky's formulation, shame is not always an acute event, but can become a "pervasive affective attunement" (Bartky, 1990: 85). Instead of experiencing shame as a discrete event with a finite duration, it can be experienced as a persistent, and perhaps, permanent possibility in daily life. This sort of pervasive or persistent shame is commonly referred to as "chronic shame" (Pattison, 2000; Nathanson, 1992; Dolezal, 2015). Chronic shame is frequently associated with political oppression and marginalization. In chronic shame, it is the potentiality of shame, rather than the actuality, that is significant. In other words, the anticipation of shame (whether explicit or implicit) comes to be a defining feature of one's lived experience. Living with chronic shame has important socio-political consequences. Thus far, chronic shame has eluded simple phenomenological analysis, largely because chronic shame often does not have a clear experiential profile: it is frequently characterised by the absence rather than the presence of shame. The aim of this article is to provide a phenomenology of chronic shame, drawing from Edmund Husserl's formulation of the 'horizon' as a means a to discuss structural aspects of chronic shame experiences, in particular how chronic shame is characterised by structures of absence and anticipation.

Philosophy and the clinic: Stigma, respect and shame

Since its foundation in 2010, the annual philosophy thematic edition of this journal has been a forum for authors from a wide range of disciplines and backgrounds, enabling contributors to raise questions of an urgent and fundamental nature regarding the most pressing problems facing the delivery and organization of healthcare. Authors have successfully exposed and challenged underlying assumptions that framed professional and policy discourse in diverse areas, generating productive and insightful dialogue regarding the relationship between evidence, value, clinical research and practice. These lively debates continue in this thematic edition, which includes a special section on stigma, shame and respect in healthcare. Authors address the problems with identifying and overcoming stigma in the clinic, interactional, structural and phenomenological accounts of stigma and the 'stigma-shame nexus'. Papers examine the lived experience of discreditation, discrimination and degradation in a range of contexts, from the labour room to mental healthcare and the treatment of 'deviancy' and 'looked-after children'. Authors raise challenging questions about the development of our uses of language in the context of care, and the relationship between stigma, disrespect and important analyses of power asymmetry and epistemic injustice. The relationship between respect, autonomy and personhood is explored with reference to contributions from an important conference series, which includes analyses of shame in the context of medically unexplained illness, humour, humiliation and obstetric violence.