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1.  Pathways Between Internalized Stigma and Outcomes Related to Recovery in Schizophrenia Spectrum Disorders 
Objective
The mechanisms by which internalized stigma affects outcomes related to recovery among people with severe mental illness have yet to be explicitly studied. This study empirically evaluated a model for how internalized stigma affects important outcomes related to recovery.
Methods
A total of 102 persons with schizophrenia spectrum disorders completed measures of internalized stigma, awareness of mental illness, psychiatric symptoms, self-esteem, hopefulness, and coping. Path analyses tested a predicted model and an alternative model for the relationships between the variables.
Results
Results from model 1 supported the view that internalized stigma increases avoidant coping, active social avoidance, and depressive symptoms and that these relationships are mediated by the impact of internalized stigma on hope and self-esteem. Results from model 2 replicated significant relationships from model 1 but also supported the hypothesis that positive symptoms may influence hope and self-esteem.
Conclusions
Findings from two models supported the hypothesis that internalized stigma affects hope and self-esteem, leading to negative outcomes related to recovery. It is recommended that interventions be developed and tested to address the important effects of internalized stigma on recovery.
doi:10.1176/appi.ps.59.12.1437
PMCID: PMC2605316  PMID: 19033171
2.  The Association between Aids Related Stigma and Major Depressive Disorder among HIV-Positive Individuals in Uganda 
PLoS ONE  2012;7(11):e48671.
Background
Major depressive disorder in people living with HIV/AIDS (PLWHA) is common and may be associated with a number of factors, including AIDS-related stigma, decreased CD4 levels, increased opportunistic infections and sociodemographic variables. The extent to which AIDS-related stigma is associated with major depressive disorder among PLWHA has not been well studied in sub-Saharan Africa. The objective of this study was to examine the associations between major depressive disorder, AIDS-related stigma, immune status, and sociodemographic variables with the aim of making recommendations that can guide clinicians.
Methods
We assessed 368 PLWHA for major depressive disorder, as well as for potentially associated factors, including AIDS-related stigma, CD4 levels, presence of opportunistic infections, and sociodemographic variables.
Results
The prevalence of major depressive disorder was 17.4%, while 7.9% of the participants had AIDS related stigma. At multivariable analysis, major depressive disorder was significantly associated with AIDS-related stigma [OR = 1.65, CI (1.20–2.26)], a CD4 count of ≥200 [OR 0.52 CI (0.27–0.99)], and being of younger age [0.95, CI (0.92–0.98).
Conclusions
Due to the high burden of major depressive disorder, and its association with AIDS related stigma, routine screening of PLWHA for both conditions is recommended. However, more research is required to understand this association.
doi:10.1371/journal.pone.0048671
PMCID: PMC3507871  PMID: 23209556
3.  Health-Related Outcomes of Adverse Childhood Experiences in Texas, 2002 
Preventing Chronic Disease  2010;7(3):A52.
Introduction
We assessed the prevalence of 7 childhood adversities (psychological, physical, and sexual abuse; household mental illness; household substance abuse; maternal battery; and incarceration of a household member) and the associations of those adversities with health outcomes.
Methods
Using data from 5,378 people who responded to the 2002 Texas Behavioral Risk Factor Surveillance System survey (which included questions about childhood adversity), we created 4 groups: no childhood abuse or household dysfunction, childhood abuse only, household dysfunction only, and both childhood abuse and household dysfunction. We examined groups by sociodemographic variables and the association with current smoking, obesity, and self-rated health.
Results
Among adult respondents, 46% reported at least 1 childhood adversity. Reports of both household dysfunction and abuse were significantly lower for college graduates than for people with less education. For those with both abuse and household dysfunction, the odds of current smoking were 1.9 and for obesity were 1.3. Compared to people without childhood adversities, people who experienced childhood adversities more frequently reported having fair or poor general health status.
Conclusion
Childhood adversities are common among Texas adults. People with childhood adversities are more likely to be socioeconomically disadvantaged, less educated, and have difficulties maintaining employment in adulthood compared to people with no adversities. Moreover, childhood adversities appear to be associated with health problems such as current smoking, obesity, and poor or fair general health among Texas adults.
PMCID: PMC2879984  PMID: 20394691
4.  Stigma towards a Neglected Tropical Disease: Felt and enacted Stigma Scores among Podoconiosis Patients in Northern Ethiopia 
BMC Public Health  2013;13:1178.
Background
Podoconiosis, or non-filarial elephantiasis, is a neglected tropical disease (NTD) characterised by swelling of the lower legs. When left untreated, this disfiguring condition has a significant social impact. This study aimed to describe the stigma experience among podoconiosis patients in Dembecha, Northern Ethiopia and assess potential associations between stigma and sociodemographic determinants.
Methods
The study was conducted in May 2012 in Northern Ethiopia. A questionnaire-based cross-sectional study design was used and stigma was assessed using a validated podoconiosis stigma scale including 'felt’ and 'enacted’ stigma domains. Enacted stigma includes the experience of discrimination such as abuse, loss of employment or prejudicial attitudes, while felt stigma is the perceived fear of enacted stigma. A multivariable linear regression model was used to explore determinants that may be associated with stigma.
Results
A total of 346 clinically confirmed podoconiosis patients participated in the study. The total mean score of all stigma scale items was 30.7 (Range = 0 to 96). There was a higher mean score of scale items in domains of felt stigma (21.7; Range = 0 to 45) as compared to enacted stigma (9.0; Range = 0 to 51). The total mean score of all stigma scale items appeared to increase with disease stage. A final adjusted linear regression model found an association between stigma and factors including monthly income, duration lived in the current residence, and disease stage, after controlling for confounders.
Conclusion
Podoconiosis is a stigmatized disease with a clear social impact. This paper documented the burden of podoconiosis-related stigma and identified associated factors. Programs aimed at preventing and treating podoconiosis should incorporate interventions to mitigate both felt and enacted stigma. Interventions targeting patients should prioritize those with advanced disease.
doi:10.1186/1471-2458-13-1178
PMCID: PMC3878751  PMID: 24330684
Podoconiosis; Stigma; Discrimination; NTD; Ethiopia
5.  Measuring Stigma in People With Lung Cancer: Psychometric Testing of the Cataldo Lung Cancer Stigma Scale 
Oncology nursing forum  2011;38(1):E46-E54.
Purpose/Objectives
To develop an instrument to measure the stigma perceived by people with lung cancer based on the HIV Stigma Scale.
Design
Psychometric analysis.
Setting
Online survey.
Sample
186 patients with lung cancer.
Methods
An exploratory factor analysis with a common factor model using alpha factor extraction.
Main Research Variables
Lung cancer stigma, depression, and quality of life.
Findings
Four factors emerged: stigma and shame, social isolation, discrimination, and smoking. Inspection of un-rotated first-factor loadings showed support for a general stigma factor. Construct validity was supported by relationships with related constructs: self-esteem, depression, social support, and social conflict. Coefficient alphas ranging from 0.75–0.97 for the subscales (0.96 for stigma and shame, 0.97 for social isolation, 0.9 for discrimination, and 0.75 for smoking) and 0.98 for the 43-item Cataldo Lung Cancer Stigma Scale (CLCSS) provided evidence of reliability. The final version of the CLCSS was 31 items. Coefficient alpha was recalculated for the total stigma scale (0.96) and the four subscales (0.97 for stigma and shame, 0.96 for social isolation, 0.92 for discrimination, and 0.75 for smoking).
Conclusions
The CLCSS is a reliable and valid measure of health-related stigma in this sample of people with lung cancer.
Implications for Nursing
The CLCSS can be used to identify the presence and impact of lung cancer stigma and allow for the development of effective stigma interventions for patients with lung cancer.
doi:10.1188/11.ONF.E46-E54
PMCID: PMC3182474  PMID: 21186151
6.  Depression and Stigma in High Risk Youth Living with HIV (YLH): A Multisite Study 
Journal of Pediatric Health Care  2011;26(4):300-305.
Introduction
This study explored the relationship between depression, stigma, and risk behaviors in a multisite study of high risk youth living with HIV (YLH) in the United States.
Methods
All youth met screening criteria for either problem level substance use, current sexual risk and/or suboptimal HIV medication adherence. Problem level substance use behavior was assessed with the CRAFFT, a 6-item adolescent screener. A single item was used to screen for current sexual risk and for a HIV medication adherence problem. Stigma and depression were measured via standard self-report measures.
Results
Multiple regression analysis revealed that behavioral infection, older age, more problem behaviors, and greater stigma each contributed to the prediction of higher depression scores in YLH. Associations between depression, stigma, and problem behaviors are discussed. More than half of the youth in this study scored at or above the clinical cut-off for depression. Results highlight the need for depression focused risk reduction interventions that address stigma in YLH.
Discussion
Study outcomes suggest that interventions are needed to address stigma and depression not only among youth living with HIV but in the communities in which they live.
doi:10.1016/j.pedhc.2011.02.014
PMCID: PMC3383773  PMID: 22726715
HIV/AIDS; Stigma; Depression
7.  Self-reports of Substance Abusers: The Relation between Social Desirability and Social Network Variables 
It is important to examine social desirability when interpreting self-report data from substance abusers. Social desirability is the tendency to respond on surveys that make people appear more favorable to others; thus, a strong desire for social approval is related to minimized reports of substance use. In the present study, the relationship between social desirability and different types of social support was examined within 582 residents of communal-living recovery homes (i.e., Oxford Houses). Although effect sizes were small, results may suggest that participants reported social network variables in a socially desirable manner; this tendency towards self-deception even predicted misrepresentations of these constructs eight months later. In addition, self-reports of the substance use habits of friends and family were more prone to social desirability than the reporting of other social network characteristics. Overall, it is suggested that social desirability might be taken into account when examining substance abusers’ self-reports of social support variables.
doi:10.1080/15560350802712397
PMCID: PMC2922763  PMID: 20721306
social desirability; social support; substance abuse recovery
8.  Predictors of HIV-related Stigma among Young People Living with HIV 
Enacted and perceived HIV-stigma was examined among substance using young people living with HIV (YPLH) in Los Angeles, San Francisco, and New York City (N = 147). Almost all YPLH (89%) reported perceived stigma and 31% report enacted experiences in the past three months; 64% reported experiences during their lifetime. The HIV-stigma questions were characterized by factors of avoidance, social rejections, abuse and shame. In multivariate models enacted stigma was associated with gay/bisexual identity, symptomatic HIV or AIDS, and bartering sex. Perceived stigma was associated with female gender, symptomatic HIV or AIDS, bartering sex, lower injection drug use, and fewer friends and family knowing serostatus. Gay/bisexual YPLH who were also HIV symptomatic or AIDS diagnosed experienced more HIV-stigma than their heterosexual peers.
doi:10.1037/0278-6133.25.4.501
PMCID: PMC2392891  PMID: 16846325
Stigma; HIV; AIDS; Youth
9.  The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review 
Addiction (Abingdon, England)  2012;107(1):39-50.
Aims
This study provides a systematic review of existing research that has empirically evaluated interventions designed to reduce stigma related to substance use disorders.
Methods
A comprehensive review of electronic databases was conducted to identify evaluations of substance use disorder related stigma interventions. Studies that met inclusion criteria were synthesized and assessed using systematic review methods.
Results
Thirteen studies met the inclusion criteria. The methodological quality of the studies was moderately strong. Interventions of three studies (23%) focused on people with substance use disorders (self-stigma), three studies (23%) targeted the general public (social stigma) and seven studies (54%) focused on medical students and other professional groups (structural stigma). Nine interventions (69%) used approaches that included education and/or direct contact with people who have substance use disorders. All but one study indicated their interventions produced positive effects on at least one stigma outcome measure. None of the interventions have been evaluated across different settings or populations.
Conclusions
A range of interventions demonstrate promise for achieving meaningful improvements in stigma related to substance use disorders. The limited evidence indicates that self-stigma can be reduced through therapeutic interventions such as group-based acceptance and commitment therapy. Effective strategies for addressing social stigma include motivational interviewing and communicating positive stories of people with substance use disorders. For changing stigma at a structural level, contact-based training and education programs targeting medical students and professionals (e.g. police, counsellors) are effective.
doi:10.1111/j.1360-0443.2011.03601.x
PMCID: PMC3272222  PMID: 21815959
Intervention studies; stigma; substance use disorders; systematic review
10.  HIV-Related Stigma, Social Norms and HIV Testing in Soweto and Vulindlela, South Africa: NIMH Project Accept (HPTN 043) 
Objective
HIV testing is necessary to curb the increasing epidemic. However, HIV-related stigma and perceptions of low likelihood of societal HIV testing may reduce testing rates. This study aimed to explore this association in South Africa, where HIV rates are extraordinarily high.
Methods
Data were taken from the Soweto and Vulindlela, South African sites of Project Accept, a multi-national HIV prevention trial. Self-reported HIV testing, stigma, and social norms items were used to study the relationship between HIV testing, stigma, and perceptions about societal testing rates. The stigma items were broken into 3 factors: negative attitudes, negative perceptions about people living with HIV, and perceptions of fair treatment for people living with HIV (equity).
Results
Results from a univariate logistic regression suggest that past history of HIV testing was associated with decreased negative attitudes about people living with HIV/AIDS, increased perceptions that people living with HIV/AIDS experience discrimination, and increased perceptions that people with HIV should be treated equitably. Results from a multivariate logistic regression confirm these effects and suggests these differences vary according to gender and age. Compared to people who had never tested for HIV, those who had previously tested were more likely to believe that the majority of people have tested for HIV.
Conclusion
Data suggest that interventions designed to increase HIV testing in South Africa should address stigma and perceptions of societal testing. Keywords: stigma, HIV testing, South Africa, Project Accept
doi:10.1097/QAI.0b013e3181fc6429
PMCID: PMC3136617  PMID: 20980913
11.  Relationships between stigma, social support, and depression in HIV-infected African American women living in the rural Southeastern United States 
This cross-sectional study examined relationships between HIV-related stigma, social support, and depression in a sample of 340 HIV-infected African American women living in rural areas of the Southeastern United States. Three aspects of social support (availability of different types of support, sources of support, and satisfaction with support) and two aspects of HIV-related stigma (perceived stigma and internalized stigma) were measured. Perceived availability of support (p < .0001), sources of support (p = .03), satisfaction with support (p = .003), perceived stigma (p < .0001), and internalized stigma (p < .0001) were all significantly correlated with depression. Social support variables were negatively correlated and stigma variables were positively correlated with depression. HIV-related perceived stigma and internalized stigma were found to mediate the effect of sources of available support on depression. Study findings have implications for designing and implementing interventions to increase social support and decrease HIV-related stigma in order to decrease depression among African American women with HIV disease.
doi:10.1016/j.jana.2009.07.008
PMCID: PMC2826539  PMID: 19879778
African American women; depression; HIV disease; HIV-related stigma; rural; social support
12.  Predictors of Quality of Life in Portuguese Obese Patients: A Structural Equation Modeling Application 
Journal of Obesity  2014;2014:684919.
Living with obesity is an experience that may affect multiple aspects of an individual's life. Obesity is considered a relevant public health problem in modern societies. To determine the comparative efficacy of different treatments and to assess their impact on patients' everyday life, it is important to identify factors that are relevant to the quality of life of obese patients. The present study aims to evaluate, in Portuguese obese patients, the simultaneous impact of several psychosocial factors on quality of life. This study also explores the mediating role of stigma in the relationship between positive/negative affect and quality of life. A sample of 215 obese patients selected from the main hospitals in Portugal completed self-report questionnaires to assess sociodemographic, clinical, psychosocial, and quality of life variables. Data were analysed using structural equation modeling. The model fitted the data reasonably well, CFI = 0.9, RMSEA = 0.06. More enthusiastic and more active patients had a better quality of life. Those who reflect lower perception of stigma had a better physical and mental health. Partial mediation effects of stigma between positive affect and mental health and between negative affect and physical health were found. The stigma is pervasive and causes consequences for psychological and physical health.
doi:10.1155/2014/684919
PMCID: PMC3945172
13.  Relationship of Stigma to HIV Risk Among Women with Mental Illness 
Urban women with severe mental illness (SMI) are vulnerable to stigma and discrimination related to mental illness and other stigmatized labels. Stigma experiences may increase their risk for negative health outcomes, such as HIV infection. This study tests the relationship between perceived stigma and HIV risk behaviors among women with SMI. The authors interviewed 92 women attending community mental health programs using the Stigma of Psychiatric Illness and Sexuality Among Women Questionnaire. There were significant relationships between personal experiences of mental illness and substance use accompanying sexual intercourse; perceived ethnic stigma and having a riskier partner type; and experiences of discrimination and having a casual or sex-exchange partner. Higher scores on relationship stigma were associated with a greater number of sexual risk behaviors. The findings underscore the importance of exploring how stigma attached to mental illness intersects with other stigmatized labels to produce unique configurations of HIV risk. HIV risk reduction interventions and prevention research should integrate attention to stigmatized identities in the lives of women with SMI.
doi:10.1037/a0014581
PMCID: PMC2791712  PMID: 19123772
women; severe mental illness; stigma; HIV sexual risk
14.  Stigma, social support, and depression among people living with HIV in Thailand 
AIDS care  2009;21(8):1007-1013.
Background
People living with HIV/AIDS (PLWHA) in Thailand face tremendous challenges, including HIV-related stigma, lack of social support, and mental health issues such as depression. This study aims to examine complex relationships among demographics, HIV-related stigma, and social support and their impact on depression among PLWHA in Thailand.
Methods
This study uses data collected in northern and northeastern Thailand. A total of 408 PLWHA were recruited and interviewed in 2007. HIV-related stigma was measured by two subscales: “Internalized Shame” and “Perceived Stigma.” Based on correlation analyses, hierarchical multiple regression models were used to examine the predictors of depression, social support, and HIV-related stigma, controlling for demographic characteristics.
Results
Correlational analysis revealed that depression was significantly associated with both dimensions of stigma: internalized shame and perceived stigma. Self-reported emotional social support was negatively associated with depression. We found that internalized shame and emotional social support were significant predictors of depression after controlling for gender, age, income, and education.
Conclusions
HIV-related stigma has a negative impact on psychological wellbeing of PLWHA in Thailand, and emotional social support remains a protective factor against depression. Intervention developers and clinicians working with PLWHA may find it useful to incorporate the association between stigma and depression into their programs and treatments, and to address social support as a protective effect for the mental health of PLWHA.
doi:10.1080/09540120802614358
PMCID: PMC2803757  PMID: 20024757
depression; stigma; PLWHA; support; Thailand
15.  Childhood trauma and health outcomes in HIV-infected patients: An exploration of causal pathways 
OBJECTIVE
Traumatic life histories are highly prevalent in people living with HIV/AIDS (PLWHA) and predict sexual risk behaviors, medication adherence, and all-cause mortality. Yet the causal pathways explaining these relationships remain poorly understood. We sought to quantify the association of trauma with negative behavioral and health outcomes and to assess whether those associations were explained by mediation through psychosocial characteristics.
METHODS
In 611 outpatient PLWHA, we tested whether trauma's influence on later health and behaviors was mediated by coping styles, self efficacy, social support, trust in the medical system, recent stressful life events, mental health, and substance abuse.
RESULTS
In models adjusting only for sociodemographic and transmission category confounders (estimating total effects), past trauma exposure was associated with 7 behavioral and health outcomes including increased odds or hazard of recent unprotected sex (OR=1.17 per each additional type of trauma, 95% CI=1.07–1.29), medication nonadherence (OR=1.13, 1.02–1.25), hospitalizations (HR=1.12, 1.04–1.22), and HIV disease progression (HR=1.10, 0.98–1.23). When all hypothesized mediators were included, the associations of trauma with health care utilization outcomes were reduced by about 50%, suggesting partial mediation (e.g., OR for hospitalization changed from 1.12 to 1.07) whereas point estimates for behavioral and incident health outcomes remained largely unchanged, suggesting no mediation (e.g., OR for unprotected sex changed from 1.17 to 1.18). Trauma remained associated with most outcomes even after adjusting for all hypothesized psychosocial mediators.
CONCLUSIONS
These data suggest that past trauma influences adult health and behaviors through pathways other than the psychosocial mediators considered in this model.
doi:10.1097/QAI.0b013e31824150bb
PMCID: PMC3299853  PMID: 22107822
Trauma; Mental health; Adherence; Health outcomes; Mediation analysis
16.  A Structural Equation Model of HIV-Related Stigma, Depressive Symptoms, and Medication Adherence 
AIDS and Behavior  2012;16(3):711-716.
HIV-related stigma has a damaging effect on health outcomes among people living with HIV (PLWH), as studies have associated it with poor HIV medication adherence and depressive symptoms. We investigated whether depressive symptoms mediate the relationship between stigma and medication adherence. In a cross-sectional study, 720 PLWH completed instruments measuring HIV-related stigma, depressive symptoms, and HIV medication adherence. We used structural equation modeling (SEM) to investigate associations among these constructs. In independent models, we found that poorer adherence was associated with higher levels of stigma and depressive symptoms. In the simultaneous model that included both stigma and depressive symptoms, depression had a direct effect on adherence, but the effect of stigma on adherence was not statistically significant. This pattern suggested that depressive symptoms at least partially mediated the association between HIV-related stigma and HIV medication adherence. These findings suggest that interconnections between several factors have important consequences for adherence.
doi:10.1007/s10461-011-9915-0
PMCID: PMC3314086  PMID: 21380495
adherence; antiretroviral treatment; stigma; depression; HIV/AIDS
17.  “We, the AIDS people …”: How Antiretroviral Therapy Enables Zimbabweans Living With Aids to Cope With Stigma 
American journal of public health  2010;101(6):1004-1010.
We studied the impact of antiretroviral treatment (ART) availability on AIDS stigma through interviews with 118 ART users, AIDS caregivers, and nurses in Zimbabwe. Treatment enables positive social and economic participation through which users can reconstruct their shattered sense of social value. However, stigma remains strong, and ART users remain mired in conflictual symbolic relationships between “the AIDS people” and “the untested.” To date, the restoration of users’ own sense of self-worth through treatment has not reduced fear and sexual embarrassment in framing community responses to people living with HIV/AIDS. Much remains to be learned about the complex interaction of the economic and psychosocial dimensions of poverty, treatment availability, and conservative sexual moralities in driving AIDS stigma in specific settings.
doi:10.2105/AJPH.2010.202838
PMCID: PMC3093282  PMID: 21164081
18.  Disentangling the stigma of HIV/AIDS from the stigmas of drugs use, commercial sex and commercial blood donation – a factorial survey of medical students in China 
BMC Public Health  2007;7:280.
Background
HIV/AIDS related stigma interferes with the provision of appropriate care and support for people living with HIV/AIDS. Currently, programs to address the stigma approach it as if it occurs in isolation, separate from the co-stigmas related to the various modes of disease transmission including injection drug use (IDU) and commercial sex (CS). In order to develop better programs to address HIV/AIDS related stigma, the inter-relationship (or 'layering') between HIV/AIDS stigma and the co-stigmas needs to be better understood. This paper describes an experimental study for disentangling the layering of HIV/AIDS related stigmas.
Methods
The study used a factorial survey design. 352 medical students from Guangzhou were presented with four random vignettes each describing a hypothetical male. The vignettes were identical except for the presence of a disease diagnosis (AIDS, leukaemia, or no disease) and a co-characteristic (IDU, CS, commercial blood donation (CBD), blood transfusion or no co-characteristic). After reading each vignette, participants completed a measure of social distance that assessed the level of stigmatising attitudes.
Results
Bivariate and multivariable analyses revealed statistically significant levels of stigma associated with AIDS, IDU, CS and CBD. The layering of stigma was explored using a recently developed technique. Strong interactions between the stigmas of AIDS and the co-characteristics were also found. AIDS was significantly less stigmatising than IDU or CS. Critically, the stigma of AIDS in combination with either the stigmas of IDU or CS was significantly less than the stigma of IDU alone or CS alone.
Conclusion
The findings pose several surprising challenges to conventional beliefs about HIV/AIDS related stigma and stigma interventions that have focused exclusively on the disease stigma. Contrary to the belief that having a co-stigma would add to the intensity of stigma attached to people with HIV/AIDS, the findings indicate the presence of an illness might have a moderating effect on the stigma of certain co-characteristics like IDU. The strong interdependence between the stigmas of HIV/AIDS and the co-stigmas of IDU and CS suggest that reducing the co-stigmas should be an integral part of HIV/AIDS stigma intervention within this context.
doi:10.1186/1471-2458-7-280
PMCID: PMC2180176  PMID: 17919317
19.  Strategies and Outcomes of HIV Status Disclosure in HIV-Positive Young Women with Abuse Histories 
AIDS Patient Care and STDs  2013;27(3):191-200.
Abstract
Young women with HIV and histories of physical and/or sexual abuse in childhood may be vulnerable to difficulties with disclosure to sexual partners. Abuse in childhood is highly prevalent in HIV-positive women, and has been associated with poorer communication, low assertiveness, low self worth, and increased risk for sexual and other risk behaviors that increase the risk of secondary transmission of HIV. HIV disclosure may be an important link between abuse and sexual risk behaviors. Qualitative interviews with 40 HIV-positive young women with childhood physical and/or sexual abuse were conducted; some women had also experienced adult victimization. Results suggest that HIV-positive women with abuse histories use a host of strategies to deal with disclosure of HIV status, including delaying disclosure, assessing hypothetical responses of partners, and determining appropriate stages in a relationship to disclose. Stigma was an important theme related to disclosure. We discuss how these disclosure processes impact sexual behavior and relationships and discuss intervention opportunities based on our findings.
doi:10.1089/apc.2012.0441
PMCID: PMC3595953  PMID: 23596649
20.  Self-report of illicit substance use versus urine toxicology results from at-risk pregnant women 
Journal of substance use  2011;16(5):372-389.
Introduction
Many factors comprise a patient's decision to disclose use of drugs. Pregnant women may report drug use because they would like help with their addiction but the stigma associated with drug use may dampen their willingness to disclose. Knowledge about the accuracy of self-reported drug use as compared to urine toxicology screens can assist clinicians in the management of substance use in pregnancy.
Method
We compared the urine toxicology screens and self-reported use of marijuana or cocaine for 168 women enrolled in an integrated obstetrical/substance abuse treatment program. We stratified by various periods of self-reported use and race and utilized Cohen's kappa to measure overall agreement between self-report and toxicology tests.
Results
Most women with a positive toxicology screen reported use in the past 28 days (78% for marijuana, 86% for cocaine). However, many women reported their most recent use to be outside of the assays’ detection window (14% for marijuana, 57% for cocaine). We did not find differences in self-report for women with positive urine between Whites and non-Whites (p = 1.00). Agreement over the previous month was good (Kappa = 0.74 and 0.70 for marijuana and cocaine, respectively.)
Summary
A question about use of marijuana or cocaine during the preceding month rather than the prior few days may be a better indicator of use.
doi:10.3109/14659891003721133
PMCID: PMC3744375  PMID: 23956685
Cocaine; marijuana; self-disclosure; urine toxicology
21.  Internalized HIV/AIDS-related Stigma in a Sample of HIV-positive People in Bangladesh 
Internalized stigma among people living with HIV/AIDS (PLHA) is prevalent in Bangladesh. A better understanding of the effects of stigma on PLHA is required to reduce this and to minimize its harmful effects. This study employed a quantitative approach by conducting a survey with an aim to know the prevalence of internalized stigma and to identify the factors associated with internalized stigma among a sample of 238 PLHA (male=152 and female=86) in Bangladesh. The findings suggest that there is a significant difference between groups with the low and the high-internalized HIV/AIDS stigma in terms of both age and gender. The prevalence of internalized stigma varied according to the poverty status of PLHA. An exploratory factor analysis (EFA) found 10 of 15 items loaded highly on the three factors labelled self-acceptance, self-exclusion, and social withdrawal. About 68% of the PLHA felt ashamed, and 54% felt guilty because of their HIV status. More than half (87.5% male and 19.8% female) of the PLHA blamed themselves for their HIV status while many of them (38.2% male and 8.1% female) felt that they should be punished. The male PLHA more frequently chose to withdraw themselves from family and social gatherings compared to the female PLHA. They also experienced a higher level of internalized stigma compared to the female PLHA. The results suggest that the prevalence of internalized stigma is high in Bangladesh, and much needs to be done by different organizations working for and with the PLHA to reduce internalized stigma among this vulnerable group.
PMCID: PMC3312356  PMID: 22524116
Acquired immunodeficiency syndrome; Discrimination; Human immunodeficiency virus; Stigma; Bangladesh
22.  Religiosity and decreased risk of substance use disorders: is the effect mediated by social support or mental health status? 
Objective
The negative association between religiosity (religious beliefs and church attendance) and the likelihood of substance use disorders is well established, but the mechanism(s) remain poorly understood. We investigated whether this association was mediated by social support or mental health status.
Method
We utilized cross-sectional data from the 2002 National Survey on Drug Use and Health (n = 36,370). We first used logistic regression to regress any alcohol use in the past year on sociodemographic and religiosity variables. Then, among individuals who drank in the past year, we regressed past year alcohol abuse/dependence on sociodemographic and religiosity variables. To investigate whether social support mediated the association between religiosity and alcohol use and alcohol abuse/dependence we repeated the above models, adding the social support variables. To the extent that these added predictors modified the magnitude of the effect of the religiosity variables, we interpreted social support as a possible mediator. We also formally tested for mediation using path analysis. We investigated the possible mediating role of mental health status analogously. Parallel sets of analyses were conducted for any drug use, and drug abuse/dependence among those using any drugs as the dependent variables.
Results
The addition of social support and mental health status variables to logistic regression models had little effect on the magnitude of the religiosity coefficients in any of the models. While some of the tests of mediation were significant in the path analyses, the results were not always in the expected direction, and the magnitude of the effects was small.
Conclusions
The association between religiosity and decreased likelihood of a substance use disorder does not appear to be substantively mediated by either social support or mental health status.
doi:10.1007/s00127-009-0124-3
PMCID: PMC2901801  PMID: 19714282
Religious activity; Substance use disorders; Mental health; Social support; Mediators
23.  Disengagement and Engagement Coping with HIV/AIDS Stigma and Psychological Well-Being of People with HIV/AIDS 
The stigma associated with HIV/AIDS poses a psychological challenge to people living with HIV/AIDS. We hypothesized that that the consequences of stigma-related stressors on psychological well-being would depend on how people cope with the stress of HIV/AIDS stigma. Two hundred participants with HIV/AIDS completed a self-report measure of enacted stigma and felt stigma, a measure of how they coped with HIV/AIDS stigma, and measures of depression and anxiety, and self-esteem. In general, increases in felt stigma (concerns with public attitudes, negative self-image, and disclosure concerns) coupled with how participants reported coping with stigma (by disengaging from or engaging with the stigma stressor) predicted self-reported depression, anxiety, and self-esteem. Increases in felt stigma were associated with increases in anxiety and depression among participants who reported relatively high levels of disengagement coping compared to participants who reported relatively low levels of disengagement coping. Increases in felt stigma were associated with decreased self-esteem, but this association was attenuated among participants who reported relatively high levels of engagement control coping. The data also suggested a trend that increases in enacted stigma predicted increases in anxiety, but not depression, among participants who reported using more disengagement coping. Mental health professionals working with people who are HIV positive should consider how their clients cope with HIV/AIDS stigma and consider tailoring current therapies to address the relationship between stigma, coping, and psychological well-being.
PMCID: PMC3355931  PMID: 22611302
Coping; HIV/AIDS; stigma; self-esteem; depression
24.  The Long-term Trajectory of Depression among Latinos in Primary Care and its Relationship to Depression Care Disparities 
General hospital psychiatry  2011;33(2):94-101.
Objective
Lower use of medication treatment, poorer doctor-patient communication, and depression stigma are key contributors to mental healthcare disparities among Latinos with depression. The current study investigated the relationship between these key variables and the long-term trajectory of depression in primary care among Latinos.
Method
Participants (N=220) were Latinos presenting to primary care who screened positive for depression. A repeated measures design was used to assess participants at baseline, 6, 25, and 30-months. Repeated measures included depression (PHQ-9), self-reported quality of doctor-patient communication, and stigma pertaining to antidepressants. Using growth curve modeling, participants' depressive symptom trajectories were examined for a 30-month period. Self-reported utilization of antidepressants, doctor-patient communication, and antidepressant stigma were examined as predictors of the depressive symptom trajectory. Also, rates of depression improvement/remission and recurrence/relapse were examined.
Results
Improvement/remission was experienced by 69.4% of participants during a 30-month period. Among those who improved/remitted at six or 25 months, 63.4% maintained that improvement/remission by 30-months. The long-term trajectory of depressive symptoms demonstrated a significant positive association with antidepressant stigma and significant negative associations with use of antidepressant treatment and quality doctor-patient communication.
Conclusions
While relapse/recurrence is common, most Latinos in this study experienced improvement in depression over 30 month. For many, there is a considerable time to reach improvement/remission. Also, these findings confirm the significance of antidepressant underutilization, doctor-patient communication, and stigma in the long-term outcome of depression among Latinos in primary care.
doi:10.1016/j.genhosppsych.2010.12.001
PMCID: PMC3197230  PMID: 21596201
25.  Community factors shaping HIV-related stigma among young people in three African countries 
AIDS care  2009;21(4):403-410.
Despite the high prevalence of HIV/AIDS that exists in many sub-Saharan African countries, very little is known of the prevalence and context of HIV-related stigma in these settings. This paper seeks to understand the community-level factors associated with HIV-related stigma among young people in three culturally contrasting African countries: Burkina Faso, Ghana and Zambia. Using nationally representative data on young people (15–24) from Burkina Faso, Ghana and Zambia, the analysis examines the economic, demographic and behavioral dimensions of community environments that shape HIV-related stigma among young people. The results demonstrate a clear influence of the community environment on shaping HIV-related stigma among young people. The elements of the community that were significantly associated with HIV-related stigma were the economic and behavioral aspects of the community environment, and there was no evidence of relationships between demographic patterns and HIV-related stigma. Behavioral change interventions must address HIV-related stigma in order to encourage behavior change, and must take into account the social, economic and cultural environments in which young people exist.
doi:10.1080/09540120802290365
PMCID: PMC2698459  PMID: 19283643
stigma; youth; Africa; community

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