Social contact as a strategy to reduce stigma in low- and middle-income countries: A systematic review and expert perspectives.

Social contact (SC) has been identified as a promising strategy for stigma reduction. Different types of SC exist. Various scholars defined positive factors to strengthen SC. This study aims to investigate the application and effectiveness of SC as a strategy to reduce stigmatisation across stigmas, settings and populations in low- and middle-income countries (LMICs). We specifically examine the use of positive factors. A systematic review was conducted in twelve electronic databases using key terms related to stigma AND social contact AND intervention AND LMICs. Data were synthesised narratively. Study quality was assessed with the Joanna Briggs Institute critical appraisal checklists. Additionally, semi-structured interviews were used with first/corresponding authors of included publications to investigate their practical experiences with SC. Forty-four studies (55 publications) were identified. Various stigmas (n = 16) were targeted, including mental health (43%). Indirect (n = 18) and direct contact (n = 16) were used most frequently, followed by collaboration, imagined and vicarious contact, or a combination. The most applied additional strategy was education. Almost half of the studies, explicitly or implicitly, described positive factors for SC, such as PWLE training or disconfirming stereotypes. The majority suggested that SC is effective in reducing stigma, although inconsistent reporting overshadows conclusions. Perspectives of people with lived experience (PWLE) were infrequently included. Expert perspectives stressed the importance of contextualisation, PWLE participation, and evaluation of SC. This study provides an overview of SC as a stigma reduction strategy within LMICs. Conclusions about which type of SC is more effective or whether SC is more effective for a specific stigma category cannot be drawn. We recommend future research to strengthen reporting on effectiveness as well as PWLE perspective and SC processes, and to further critically examine the potential of SC. An overview of positive factors applied to strengthen SC is provided, which can stimulate reflection and guide future SC.

Reducing stigma impacting children and adolescents in low- and middle-income countries: The development of a common multi-component stigma reduction intervention.

INTRODUCTION: Stigmatisation impedes health and quality of life. Evidence regarding stigma reduction interventions is, albeit growing, limited. There is a gap in the availability and evidence of interventions for reducing stigma among children and adolescents, especially in low- and middle-income countries. This paper describes the process that led to a stigma reduction intervention impacting children and adolescents in low- and middle-income countries, following previously conducted formative research. METHODS: In this study, we conducted (i) online stakeholder consultations (FGD) (n = 43), including a survey assessing intervention acceptability, appropriateness, feasibility and scalability (n = 16); and (ii) preliminary field-testing of intervention content online and in a refugee settlement in Uganda. FINDINGS: Stakeholder consultation showed the initial version of STRETCH (Stigma Reduction to Trigger Change for Children), albeit positively received, required adaptations. We made adjustments to i) take into account implementation duration, intervention flexibility and intersectionality; (ii) strengthen the involvement of individuals, including adolescents/youth, with lived stigma experience; (iii) target people close to individuals with lived stigma experience; and (iv) address feasibility and sustainability concerns. Preliminary field-testing simplified STRETCH while adding a community outreach component and revisiting the intervention setup, to ensure STRETCH can also be applied from a modular perspective. CONCLUSION: We conducted a process to develop a child-focused multi-component stigma reduction intervention, with intended applicability across stigmas and settings. This paper provides an overview of the intervention development process, generating intervention-specific learnings with generic value. STRETCH aims to reduce stigmatisation at the implementing organisation, create community-wide reflection and stigma reduction demand, and reduce stigmatisation among various target groups.

Assessing stigma in low- and middle-income countries: A systematic review of scales used with children and adolescents.

INTRODUCTION: Stigmatization contributes to health inequalities, impacting the wellbeing of children and adolescents negatively. Addressing stigmatization requires adequate measurement. Our systematic review synthesizes the content of scales used with children and adolescents in low- and middle-income countries (LMICs) across stigmas, and examines their comparability and level of cultural adaptation. METHODS: Ten databases were systematically searched combining three sets of search terms: (i) stigma, (ii) scales, and (iii) LMICs. Studies conducted in LMICs, with a sample with mean age below 18 and reporting a minimum of one stigma scale, were eligible. We allocated scale items to four frameworks: (i) dimensions, or drivers of stigmatization; (ii) target variants, or types of stigmatization; (iii) socio-ecological levels, and (iv) cross-cultural equivalence, or scale adaptation to context/population. Based on percentages, we compared scale content per age cohort, stigma status, region, and stigma category. RESULTS: Out of 14,348 records, we included 93 articles (112 scales). Most studies focused on adolescents (12-18 years). Twelve scales were used more than once, seven were used across regions, and four were employed for multiple stigmas. Physical health stigma, and HIV/AIDS-related stigma in particular, was measured most; mental health and multiple/generic stigmas least. Physical and mental health scales were generally more comprehensive, i.e., measuring more stigma facets. In general, scales consistently measured two of the 21 included stigma facets, namely the disruptiveness dimension and the community level. Cross-cultural equivalence was moderate; conceptual and measurement equivalence were high. DISCUSSION: Although scales were largely comparable in how they measure stigma, they failed to reflect the complexity of the stigmatization process and fell short of existing stigma frameworks and qualitative research. Stigma research with children should work towards cross-culturally validated stigma scale sets which incorporate more facets of existing stigma frameworks, thus facilitating comparability across cultural contexts and informing intervention development and evaluation.

Stigma reduction interventions for children and adolescents in low- and middle-income countries: Systematic review of intervention strategies.

Stigmatisation and discrimination are common worldwide, and have profound negative impacts on health and quality of life. Research, albeit limited, has focused predominantly on adults. There is a paucity of literature about stigma reduction strategies concerning children and adolescents, with evidence especially sparse for low- and middle-income countries (LMIC). This systematic review synthesised child-focused stigma reduction strategies in LMIC, and compared these to adult-focused interventions. Relevant publications were systematically searched in July and August 2018 in the following databases; Cochrane, Embase, Global Health, HMIC, Medline, PsycINFO, PubMed and WorldWideScience.org, and through Google Custom Search. Included studies and identified reviews were cross-referenced. Three categories of search terms were used: (i) stigma, (ii) intervention, and (iii) LMIC settings. Data on study design, participants and intervention details including strategies and implementation factors were extracted. Within 61 unique publications describing 79 interventions, utilising 14 unique stigma reduction strategies, 14 papers discussed 21 interventions and 10 unique strategies involving children. Most studies targeted HIV/AIDS (50% for children, 38% for adults) or mental illness (14% vs 34%) stigma. Community education (47%), individual empowerment (15%) and social contact (12%) were most employed in child-focused interventions. Most interventions were implemented at one socio-ecological level; child-focused interventions mostly employed community-level strategies (88%). Intervention duration was mostly short; between half a day and a week. Printed or movie-based material was key to deliver child-focused interventions (37%), while professionals most commonly implemented adult-focused interventions (53%). Ten unique, child-focused strategies were all evaluated positively, using a diverse set of scales. Children and adolescents are under-represented in stigma reduction in LMIC. More stigma reduction interventions in LMIC, addressing a wider variety of stigmas, with children as direct and indirect target group, are needed. This systematic review is registered under International Prospective Register of Systematic Reviews PROSPERO, reference number #CRD42018094700.