Stigma

How do you improve stigma at a health service level?

- Plan services that are accessible to marginalised groups - Recognise the inverse care law proposed by Julian Tudor Hart (a South Wales GP) in 1971 that good medical or social care tends to vary inversely with the need of the population served

What law protects people from stigma?

2010 equality act has been brought in to ensure that not only is discrimination made unlawful but also its aim is to promote equality of opportunity and to foster good relations. The Equalities Act does not require Public Bodies to remove or ignore the differences between people. The differences between people make up a heterogeneous society.

What is stigma?

A label or stereotype that links a person to unfavourable characteristics "a negatively defined attribute, trait, condition or behaviour conferring 'deviant' status, which is socially, culturally and historically variable"

What is stigma coaching?

Advice given on how a patient should socially manage a stigmatised illness can contribute to the stigma. The stigma associated with epilepsy is such that some people are advised to maintain secrecy about their symptoms and their diagnostic label - only revealing it when it is considered necessary. People with epilepsy, for example, have said that often over-concerned parents and medical professionals have given advice not to mention the diagnosis to strangers or employers. This form of advice has been labelled 'stigma coaching' because it can contribute to the stigma by encouraging a practice of concealment and hiding.

What is courtesy stigma?

Courtesy Stigma describes stigma not felt directly by the person by the person with an illness, but may be experienced by a carer who may feel ashamed or embarrassed by the person who is ill. That is, stigma spreads to others close to the person who is directly affected. An example may be a parent taking their child who has autism to a restaurant, or the son who is taking his elderly father who has mental health issues to the supermarket.

What is cultural stereotyping?

Cultural Stereotyping: Gender, Race, age and SE status also stigmatize patients in the health care system, in as much as prejudice exists resulting in health care disparity and poor health outcomes in the stigmatized group. It is the result of collective attitudes that groups hold towards a stigmatizing condition.

What is a discredited person?

Discredited - if the condition has aspects or attributes that are clearly visible or apparent, and the person cannot conceal these attributes, for example facial scarring following a burn. The problem for the discredited person will be to control the part of the interaction that focuses on these blemished parts; a key task of any interaction is to manage tension.

What is enacted stigma?

Enacted stigma: is what happens when a person or group is shunned, denied protection under the law or dehumanized. It describes the actual first-hand experience of stigma. In health this may include patients being treated differently than other patients; has been found to be common in groups if people with epilepsy, certain infectious diseases (HIV/AIDS), obesity, substance abuse, mental illness and physical disability.

What is felt or self stigma?

Felt or Self Stigma: describes feelings such as shame that interfere with a person asking for help. It describes the fear or shame that an individual or group may have that they, and their condition, will be negatively viewed. It occurs when people internalise enacted stigma ie when believe the enacted stigma focused on them. An example might be someone visiting a GUM clinic for the first time.

Why does having a 'legitimate illness' matter? Give some criteria of a legitimate illness

Friedson argued that entry into the sick role is not always guaranteed. It depends on how serious it is and how legitimate it is. A legitimate illness is one that society perceives as real. 1. If an illness is incurable (eg cancer), and because a person cannot act to get well, access to the sick role is 'unconditionally legitimate' 2. If it is feasible for a person to get well, and their disease can be treated, entry into the sick role is 'conditional' 3. if the illness is stigmatized by others, a person's access to the sick role may be considered 'illegitimate'.

Give some examples of diseases which were stigmatised: Historically Classically Contemporarily

HISTORICAL: Tuberculosis, Leprosy, Epilepsy CLASSIC: HIV/AIDS. Mental illness CONTEMPORARY: Chronic Illness ('welfare to work'), 'Lifestyle' Diseases (obesity), Non organic diseases (eg Chronic fatigue Syndrome), Hep C,

Is stigma variable?

It is important to understand that stigma is socially and historically variable and what is discouraged or perceived negatively may be affected by when or where you live. For example having a large body size is celebrated in some countries because it implies wealth; rather than greed and laziness as it has come to be perceived in UK and North America. Smoking used to be accepted and encouraged. At different times, different attributes and behaviours may be discrediting

How has medicine added to stigma?

One way that medicine has been argued to have a role in contributing to the stigmatizing of illness is in the of labelling of disease, in so far as diagnostic categories are also ways of describing and categorising behaviour.

How do you improve stigma at a societal level?

Review the social and moral bases of programmes of treatment and care Influence policy to understand what society does to individuals (discrimination, prejudice oppression) and formulate ways to improve health outcomes for all.

What creates stigma?

The concept of DEVIANCE relies mostly on the idea that when we do not act in the way society expects we can be subjected to sanctions. We can recognise deviance in some medical conditions because the disease might require us to control the behaviour associated with illness, or to justify why we cannot meet our expected social roles and obligations. The extent to which a person is granted the rights and privileges of the "sick role" (including the right to be exempt from work and social obligation) depends on the perception of the seriousness of the disease and its legitimacy.

Why might stigma have an emotional effect on a health care professional?

This is particularly true where a health professional has the desire to, but is unable to adequately engage with a patient's concerns.

How might someone cope with stigma?

choose to accept or reject stigmatising view pass as normal alter appearance through surgery withdraw compliance, or adoption of a compliant facade actively resist conform to a stereotype (an elderly person may find it easier to appear senile as it fits expectations) performance (ie acting more incapacitated than one is) people who are physically disabled may experience a number of these coping mechanisms when they meet someone new and unfamiliar with their disability, but that they often experience a kind of 'Fictional acceptance' when they first meet strangers.

How do you improve stigma at an individual level?

focus on how patients rationalise their own illness (personal and societal meanings) and what meaning they take from their symptoms avoid making assumptions about what the patient may be thinking try to see the illness form the patient's perspective act in a way that avoids stigmatizing judgements recognise that when making a diagnosis this may bring with it the unwanted baggage of societal attitudes towards that illness manage your personal stresses, anxieties and pressures as a doctor to ensure that you give your best for the individual in front of you.

What are some reasons for non-compliance?

i) communication failures (between doctor and patient) ii) poor experience of treatment by patients iii) lack of belief in diagnosis/prognosis by patients iv) an attempt by patients to maintain a sense of personal autonomy and freedom v) the absence of a compliance culture vii) the stigmatizing of patients (who are labelled as irrational, obstructive to medical recovery due to a deviation from acceptable norms for engagement in medical processes).

What is a discredible person?

if the condition has aspects that are invisible or can be hidden and the person can conceal these attributes, therefore the attributes are only potentially stigmatizing, for example trunk scarring following a burn. The problem for the discreditable person will be to how to manage others and how they might respond to information about their blemished aspects.