Structural determinants of stigma across health and social conditions: a rapid review and conceptual framework to guide future research and intervention

Dementia-Inclusive Choices for Exercise Toolkit: Impact on the Knowledge, Perspectives, and Practices of Exercise Providers

Physical activity improves the well-being of persons living with dementia but few exercise programs include them. The Dementia-Inclusive Choices for Exercise (DICE) toolkit aims to improve exercise providers' understanding of dementia and ability to support persons living with dementia in physical activity. We evaluated the co-designed DICE toolkit with exercise providers using a mixed-methods approach comprising pre/post questionnaires and interviews and reflection diaries. Among 16 participants, self-efficacy for exercise delivery to persons living with dementia and both knowledge and attitudes toward dementia significantly improved. Thematic analysis suggested participants (a) had a deeper understanding of the variability of dementia, (b) were planning for equitable access for persons living with dementia, (c) planned to promote social connection through exercise, and (d) were optimistic for future engagement with persons living with dementia. The DICE toolkit may improve exercise providers' knowledge and confidence to plan proactively to support persons living with dementia in programs and services.

The Social Context: Social and Behavioral Factors That Affect Health Outcomes

To achieve understanding and best care, screening and treating patients should consider the patient's social environment. Social and behavioral factors influence both positive and negative health behaviors that influence mental and physical health. Primary care providers continually navigate barriers faced by patients and seek solutions that take into consideration social and behavioral factors. The role of the PCP begins with an understanding of common barriers and community resources, then by assessing and responding to the patient's own challenges, and finally by advocating in the clinic and public for changes to the underlying social and structural causes of morbidity and mortality.

Screening and Referral for Social Determinants of Health: Maternity Patient and Health Care Team Perspectives

Objective

To identify patient and health care team perspectives on screening and referral for Social Determinants of Health (SDoH) in maternity care.

Methods

This human-centered design study was conducted in a prenatal clinic and in the surrounding community of a university teaching hospital in the Southeastern United States. Qualitative data were collected through semistructured interviews and focus groups between March 2019 and February 2020, with findings shared in-person with participants for feedback.

Results

A total of 19 English- and Spanish-speaking patients and 11 health care team members participated. Participants suggested that all patients should be screened as part of integrated health assessments, early in care and periodically, but only when protocols are in place for addressing needs-immediate or ongoing. They expressed concerns that disclosure of SDoH screening data might exacerbate already existing biases, negatively impact care, or be used to harm them. Patients wanted proactive transparency about the purpose of SDoH screening, and to know who would have access to their data, when and how it would be used, and how long it would be stored. Patients expressed concern about confidentiality and stigma, and wanted their health care team to normalize seeking help, and acknowledge that birthing people's circumstances change over time. Patients and health care team responded that patient-provider communication should be respectful, be antiracist, and demonstrate respect for patient autonomy.

Conclusion

Patients and health care team members recommended that SDoH resource information be accessible to all patients regardless of endorsed needs.

The social determinants of substance use associated with deaths of despair: Individual risks and population impacts

As the incidence of deaths from external causes including poisonings, suicide, and alcohol-related liver disease, increases in countries such as the United States and Canada, a better understanding of the fundamental social determinants of the substance use underlying these so-called "deaths of despair", at the population level, is needed. Using data from the nationally representative data from the Canadian Community Health Survey (2003, 2015-2016, 2018 cycles) (N = 30,729), the independent associations between age, sex, marital status, immigrant status, race/ethnicity, education, income, rurality, affective health and the use of illicit substances, opioids (without distinction for prescription status), problematic levels of alcohol, and combined past-year use (≥2) of substances, were explored using multivariate logistic regression, marginal risk, and population attributable fraction estimation, with propensity score-adjusted sensitivity analyses. Males, those who were under 29 years, without a partner, born in Canada, White, or had an affective disorder reported both higher use of individual substances and multiple substances in the past year. Social determinants appear to explain a substantial proportion of substance use patterns overall. Between 10% and 45% of illicit substance, problematic alcohol, and polysubstance use prevalence was attributable to non-partnered marital status, non-immigrant status, and White race/ethnicity. Of opioid use prevalence, 25% was attributable to White race/ethnicity, 13% to affective disorder status and 4% to lower-income. Though not all substance use will result in substance-related morbidity or mortality, these findings highlight the role of social determinants in shaping the intermediary behavioural outcomes that shape population-level risk of "deaths of despair".

Integrating time into stigma and health research

Stigma changes over time: it waxes and wanes through history, is manifested within humans who develop over time and is tied to statuses (such as attributes, illnesses and identities) that have varying courses. Despite the inherent fluidity of stigma, theories, research and interventions typically treat associations between stigma and health as stagnant. Consequently, the literature provides little insight into when experiences of stigma are most harmful to health and when stigma interventions should be implemented. In this Perspective, we argue that integrating time into stigma research can accelerate progress towards understanding and intervening in associations between stigma and health inequities. We situate time in relation to key concepts in stigma research, identify three timescales that are relevant for understanding stigma (historical context, human development and status course), and outline a time-based research agenda to improve scientists’ ability to understand and address stigma to improve health.

Associations between stigma and health are typically treated as stagnant. In this Perspective, Earnshaw et al. argue that considering stigma in relation to historical, human development and status course timescales can advance progress in understanding and addressing stigma to improve health.

The impact of stigma on HIV testing decisions for gay, bisexual, queer and other men who have sex with men: a qualitative study

Background

Stigmatization may prompt gay, bisexual, queer and other men who have sex with men (GBQMSM) to avoid or delay HIV testing. There has been little attention to GBQMSMs’ perspectives about how stigma may influence their decisions about whether, where, and how often to get tested for HIV.

Methods

We conducted nine focus groups with 64 adult GBQMSM in Metropolitan Detroit, including HIV-negative men and people living with HIV (PLWH). Data were thematically analyzed deductively and inductively in three rounds.

Results

Three themes emerged regarding whether to get tested: (1) Perceived promiscuity, risk perceptions and HIV testing; (2) Fearing sexual rejection; and (3) Fearing friend and family member distancing and rejection. Themes concerning where to get tested included: (4) Conflating HIV testing and diagnosis; and (5) Seeking privacy and safety at specialized services. As for how often to get tested, themes included: (6) Reducing contact with healthcare providers due to intersectional stigma; (7) Responsibility and regular testing; and (8) HIV stigma and testing as routine care. Black participants articulated themes (3), (4), and (6) with greater frequency than other participants. Framing HIV testing as a personal responsibility may have created a “new stigma,” with unintended consequences not observed with “routine healthcare” messaging.

Conclusions

GBQMSMs’ perspectives indicate the potential for new foci for HIV testing promotion interventions based on stigma-related issues that they deem important. There is a need for interventions to challenge the “promiscuity” stereotype, and to reduce the sexual stigmatization of GBQMSM living with HIV/AIDS—especially online. Provider stigma requires both intervention and continued availability of specialized services. Future stigma-reduction interventions for Black GBQMSM could focus on building family support/acceptance, awareness of multiple testing options, and integrating LGBTQ-related issues into initiatives for racial justice in health care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12761-5.