What ways would you choose to function as an advocate for vulnerable populations?
Discuss the types of assistance you might provide to each of the following clients from a vulnerable population:
A 24-year-old pregnant woman who is currently homeless and unmarried
A 16-year-old girl who has run away from her foster home and who has an IV drug habit
An immigrant worker whose TB skin test just came back positive
An employed, married man who contracted Hepatitis B through a blood transfusion 30 years ago
With a society that is so diverse in its own nature, issues pertaining to cultural diversity are bound to occur in the process of team management and leadership. Using the South University Online Library or the Internet, research about cultural diversity. Based on your research and understanding, answer the following questions:
How does having members of different cultures on a team affect the team’s performance?
How would you incorporate a person from a culture of your choice into your team, keeping in mind communication differences within your and the chosen culture? Stigma Associated with Disease Essay
Stigma is when someone views you in a negative way because you have a distinguishing characteristic or personal trait that’s thought to be, or actually is, a disadvantage (a negative stereotype). Unfortunately, negative attitudes and beliefs toward people who have a mental health condition are common.
Stigma can lead to discrimination. Discrimination may be obvious and direct, such as someone making a negative remark about your mental illness or your treatment. Or it may be unintentional or subtle, such as someone avoiding you because the person assumes you could be unstable, violent or dangerous due to your mental illness. You may even judge yourself.
Some of the harmful effects of stigma can include:
Reluctance to seek help or treatment
Lack of understanding by family, friends, co-workers or others
Fewer opportunities for work, school or social activities or trouble finding housing
Bullying, physical violence or harassment
Health insurance that doesn’t adequately cover your mental illness treatment
The belief that you’ll never succeed at certain challenges or that you can’t improve your situation
Steps to cope with stigma
Here are some ways you can deal with stigma: Stigma Associated with Disease Essay
Get treatment. You may be reluctant to admit you need treatment. Don’t let the fear of being labeled with a mental illness prevent you from seeking help. Treatment can provide relief by identifying what’s wrong and reducing symptoms that interfere with your work and personal life.
Don’t let stigma create self-doubt and shame. Stigma doesn’t just come from others. You may mistakenly believe that your condition is a sign of personal weakness or that you should be able to control it without help. Seeking counseling, educating yourself about your condition and connecting with others who have mental illness can help you gain self-esteem and overcome destructive self-judgment.
Don’t isolate yourself. If you have a mental illness, you may be reluctant to tell anyone about it. Your family, friends, clergy or members of your community can offer you support if they know about your mental illness. Reach out to people you trust for the compassion, support and understanding you need.
Don’t equate yourself with your illness. You are not an illness. So instead of saying “I’m bipolar,” say “I have bipolar disorder.” Instead of calling yourself “a schizophrenic,” say “I have schizophrenia.”
Join a support group. Some local and national groups, such as the National Alliance on Mental Illness (NAMI), offer local programs and internet resources that help reduce stigma by educating people who have mental illness, their families and the general public. Some state and federal agencies and programs, such as those that focus on vocational rehabilitation and the Department of Veterans Affairs (VA), offer support for people with mental illness. Stigma Associated with Disease Essay
Get help at school. If you or your child has a mental illness that affects learning, find out what plans and programs might help. Discrimination against students because of a mental illness is against the law, and educators at primary, secondary and college levels are required to accommodate students as best they can. Talk to teachers, professors or administrators about the best approach and resources. If a teacher doesn’t know about a student’s disability, it can lead to discrimination, barriers to learning and poor grades.
Speak out against stigma. Consider expressing your opinions at events, in letters to the editor or on the internet. It can help instill courage in others facing similar challenges and educate the public about mental illness.
Others’ judgments almost always stem from a lack of understanding rather than information based on facts. Learning to accept your condition and recognize what you need to do to treat it, seeking support, and helping educate others can make a big difference.
Stigma is when someone sees you in a negative way because of a particular characteristic or attribute (such as skin colour, cultural background, a disability or a mental illness). When someone treats you in a negative way because of your mental illness, this is discrimination. Stigma Associated with Disease Essay
Stigma happens when a person defines someone by their illness rather than who they are as an individual. For example, they might be labelled ‘psychotic’ rather than ‘a person experiencing psychosis’.
For people with mental health issues, the social stigma and discrimination they experience can make their problems worse, making it harder to recover. It may cause the person to avoid getting the help they need because of the fear of being stigmatised.
The harmful effects of stigma
Some of the effects of stigma include:
feelings of shame, hopelessness and isolation
reluctance to ask for help or to get treatment
lack of understanding by family, friends or others
fewer opportunities for employment or social interaction
bullying, physical violence or harassment
self-doubt – the belief that you will never overcome your illness or be able to achieve what you want in life.
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Dealing with stigma
Here are some ways you can deal with stigma: Stigma Associated with Disease Essay
Get the mental health treatment you need. Try not to let the fear of being labelled with a mental illness stop you from getting help.
Do not believe it. Sometimes, if you hear or experience something often enough, you start to believe it yourself. Try not to let other people’s ignorance influence the way you feel about yourself. Mental illness is not a sign of weakness and is rarely something you can deal with on your own. Talking about your mental health issues with healthcare professionals will help you on your road to recovery or management.
Do not hide away. Many people with mental illness want to isolate themselves from the world. Reaching out to people you trust – family, friends, coaches or religious leaders – can mean you get the support you need.
Connect with others. Joining a mental health support group – either online or in person – can help you deal with feelings of isolation and make you realise that you are not alone in your feelings and experiences.
You are not your illness. Do not define yourself by your illness as other people might. Instead of saying ‘I’m schizophrenic’, say ‘I have schizophrenia’. There is power in language.
It’s not personal. Remember that other people’s judgements often come from a lack of understanding rather than anything else. These judgments are made before they get to know you, so do not believe that their views have anything to do with you personally.
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Discrimination – your rights
Australia has legislation against discrimination and agrees with international conventions that protect the rights of people with mental illness. Stigma Associated with Disease Essay
The Victorian Equal Opportunity and Human Rights Commission promotes equal opportunity and can help you address unlawful discrimination.
The Australian Human Rights Commission is a Commonwealth Government agency that promotes human rights and deals with compliance and discrimination.
At the international level, the United Nations General Assembly has ‘Principles for the protection of persons with mental illness and the improvement of mental health care’. The World Health Organization also has information on mental health and human rights.
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Challenging stigma associated with mental illness
Everyone has a role to play in creating a mentally healthy community – one that is inclusive, rejects discrimination and supports recovery. Ways to help include:
learning the facts about mental illness and sharing them with family, friends, work colleagues and classmates
getting to know people with personal experiences of mental illness so you learn to see them for the person they are rather than their illness.
not judging, label or discriminate when you meet people with mental illness. Treat all people with respect and dignity.
avoiding using language that puts the illness first and the person second. Say ‘a person with bipolar disorder’ rather than ‘that person is bipolar’. Stigma Associated with Disease Essay
saying something when you hear people around you making stereotypical or inaccurate comments about mental illness.
sharing your own experience of mental illness (if you have experienced it). This will help dispel myths and encourage others to do the same. Mental illness is not something shameful that needs to be hidden.
HIV-related stigma and discrimination refers to prejudice, negative attitudes and abuse directed at people living with HIV and AIDS. In 35% of countries with available data, over 50% of people report having discriminatory attitudes towards people living with HIV.1
Stigma and discrimination also makes people vulnerable to HIV. Those most at risk to HIV (key affected populations) continue to face stigma and discrimination based on their actual or perceived health status, race, socioeconomic status, age, sex, sexual orientation or gender identity or other grounds. Stigma Associated with Disease Essay
Stigma and discrimination manifests itself in many ways. Discrimination and other human rights violations may occur in health care settings, barring people from accessing health services or enjoying quality health care.3 Some people living with HIV and other key affected populations are shunned by family, peers and the wider community, while others face poor treatment in educational and work settings, erosion of their rights, and psychological damage. These all limit access to HIV testing, treatment and other HIV services.4 5
The People Living with HIV Stigma Index documents the experiences of people living with HIV. As of 2015, more than 70 countries were using the HIV Stigma Index, more than 1,400 people living with HIV had been trained as interviewers, and over 70,000 people with HIV have been interviewed.6 Findings from 50 countries, indicate that roughly one in every eight people living with HIV is being denied health services because of stigma and discrimination.7
Why is there stigma around HIV and AIDS?
Whenever AIDS has won, stigma, shame, distrust, discrimination and apathy was on its side. Every time AIDS has been defeated, it has been because of trust, openness, dialogue between individuals and communities, family support, human solidarity, and the human perseverance to find new paths and solutions.
– Michel Sidibé, Executive Director of UNAIDS8
The fear surrounding the emerging HIV epidemic in the 1980s largely persists today. At that time, very little was known about how HIV is transmitted, which made people scared of those infected due to fear of contagion. Stigma Associated with Disease Essay
This fear, coupled with many other reasons, means that lots of people falsely believe:
HIV and AIDS are always associated with death
HIV is associated with behaviours that some people disapprove of (such as homosexuality, drug use, sex work or infidelity)
HIV is only transmitted through sex, which is a taboo subject in some cultures
HIV infection is the result of personal irresponsibility or moral fault (such as infidelity) that deserves to be punished
inaccurate information about how HIV is transmitted, which creates irrational behaviour and misperceptions of personal risk.9
How stigma affects people living with HIV
My daughter refused to go hospital to receive medicines. My daughter died because of the fear of stigmatization and discrimination
– Patience Eshun from Ghana, who lost her daughter to an AIDS-related illness10
HIV-related stigma and discrimination exists worldwide, although it manifests itself differently across countries, communities, religious groups and individuals. In sub-Saharan Africa, for example, heterosexual sex is the main route of infection, which means that HIV-related stigma in this region is mainly focused on infidelity and sex work. Stigma Associated with Disease Essay
Research by the International Centre for Research on Women (ICRW) outlines the possible consequences of HIV-related stigma as:
loss of income and livelihood
loss of marriage and childbearing options
poor care within the health sector
withdrawal of caregiving in the home
loss of hope and feelings of worthlessness
loss of reputation.12
HIV stigma and key affected populations
Stigma and discrimination is often directed towards key affected populations such as men who have sex with men (sometimes referred to as MSM), people who inject drugs and sex workers.
Graphic showing how stigma leads to sickness
These people are increasingly marginalised, not only from society, but from the services they need to protect themselves from HIV. For example, in 2016, 60% of countries in the European Economic Area reported that health care professionals’ negative and discriminatory attitudes towards men who have sex with men and people who inject drugs hampered the provision of adequate HIV prevention services for these groups. Stigma Associated with Disease Essay
More than 90% of new HIV infections in Central Asia, Europe, North America, the Middle East and North Africa in 2014 were among people from key populations and their sexual partners, who accounted for 45% of new HIV infections worldwide in 2015.14 Recent studies suggest that, globally, people who inject drugs are 24 times more likely to acquire HIV than the general population, sex workers are 10 times more likely and men who have sex with men are 24 times more likely. Moreover, transgender people are 49 times more likely and prisoners are five times more likely to be living with HIV than adults in the general population.15
Graphic showing what we can do about stigma
How stigma affects the HIV response
UNAIDS and the World Health Organization (WHO) cites fear of stigma and discrimination as the main reason why people are reluctant to get tested, disclose their HIV status and take antiretroviral drugs (ARVs).16
One study found that participants who reported high levels of stigma were over four times more likely to report poor access to care.17 This contributes to the expansion of the global HIV epidemic and a higher number of AIDS-related deaths.
An unwillingness to take an HIV test means that more people are diagnosed late, when the virus may have already progressed to AIDS. This makes treatment less effective, increasing the likelihood of transmitting HIV to others, and causing early death.
For example, in the United Kingdom (UK), many people who are diagnosed with HIV are diagnosed at a late stage of infection, defined as a CD4 count under 350 within three months of diagnosis. Although late diagnosis of HIV has declined in the UK in the last decade, from 56% in 2005 to 39% in 2015, this figure remains unacceptably high.18
In South Africa, stigma stopped many young women involved in a trial on HIV prevention from using vaginal gels and pills that would help them stay HIV free. Many reported being afraid that using these products would lead them to being mistakenly identified as having HIV, and so the fear of the isolation and discrimination that being identified as living with HIV would bring led them to adapt behaviours that put them more at risk of acquiring the virus.19
The epidemic of fear, stigmatization and discrimination has undermined the ability of individuals, families and societies to protect themselves and provide support and reassurance to those affected. This hinders, in no small way, efforts at stemming the epidemic. It complicates decisions about testing, disclosure of status, and ability to negotiate prevention behaviours, including use of family planning services. Stigma Associated with Disease Essay
In 2015, WHO released new treatment guidelines that reflect the need to address stigma and discrimination as a barrier to accessing HIV treatment.21
Forms of HIV stigma and discrimination
HIV and AIDS-related stigma can lead to discrimination, for example, when people living with HIV are prohibited from travelling, using healthcare facilities or seeking employment.
Self-stigma, or internalised stigma, has an equally damaging effect on the mental wellbeing of people living with HIV or from key affected populations. This fear of discrimination breaks down confidence to seek help and medical care.22
Self-stigma and fear of a negative community reaction can hinder efforts to address the HIV epidemic by continuing the wall of silence and shame surrounding the virus. Negative self-judgement resulting in shame, worthlessness and blame represents an important but neglected aspect of living with HIV. Self-stigma affected a person’s ability to live positively, limits meaningful self agency, quality of life, adherence to treatment and access to health services.23
In Zimbabwe, Trócaire and ZNNP+ designed, implemented and evaluated a 12-week pilot programme to support people living with HIV to work through self-stigmatising beliefs. After the 12 weeks, participants reported profound shifts in their lives. The majority of participants (61%) reported a reduction in self-stigma, depression (78%) and fears around disclosure (52%), and increased feelings of satisfaction (52%) and daily activity (70%). Stigma Associated with Disease Essay
Evidence suggests people from key affected populations are also disproportionally affected by self-stigma. For example, a study of men in China who have sex with men found that depression experienced by participants due to feelings of self stigma around homosexuality directly affected HIV testing uptake.25
Similarly, a study of men in Tijuana, Mexico who have sex with men found that self-stigma was strongly associated with never having tested for HIV, while testing for HIV was associated with identifying as being homosexual or gay and being more ‘out’ about having sex with men.26
In countries that are hostile to men who have sex with men and other key populations, innovative strategies are needed to engage individuals in HIV testing and care programmes without exacerbating experiences of stigma and discrimination.
I am afraid of giving my disease to my family members-especially my youngest brother who is so small. It would be so pitiful if he got the disease. I am aware that I have the disease so I do not touch him. I talk with him only. I don’t hold him in my arms now. Stigma Associated with Disease Essay
– woman in Vietnam 27
A country’s discriminatory laws, rules and policies regarding HIV can alienate and exclude people living with HIV, reinforcing the stigma surrounding HIV and AIDS.
In 2014, 64% of countries reporting to UNAIDS had some form of legislation in place to protect people living with HIV from discrimination.28 While, conversely, 72 countries have HIV-specific laws that prosecute people living with HIV for a range of offences.29
Criminalisation of key affected populations remains widespread with 60% of countries reporting laws, regulations or policies that present obstacles to providing effective HIV prevention, treatment, care and support.30 As of 2016, 73 countries criminalised same sex activity,31 and injecting drugs use is widely criminalised, leading to high incarceration levels among people who use drugs.32 Stigma Associated with Disease Essay
More than 100 countries criminalise sex work or aspects of sex work.33 Even in countries where sex work is at least partially legal the law rarely protects sex workers and many are at risk of discrimination, abuse and violence from both state and non-state actors such as law enforcement, partners, family members and their clients.34 For example, some 15,000 sex workers in China were detained in so-called custody and education centres in 2013.35
Case study: Ending criminalisation of HIV transmission in Australia
Laws that criminalise HIV non-disclosure, exposure and transmission perpetuate stigma and deter people from HIV testing and puts the responsibility of HIV prevention solely on the partner living with HIV.36
In May 2015, the Australian state of Victoria repealed the country’s only HIV-specific law criminalising the intentional transmission of HIV. The repealed law – Section 19A of the Crimes Act 1958 – carried a maximum penalty of 25 years imprisonment, even more than the maximum for manslaughter (which is 20 years).37
The legislation to repeal the law was developed through the collaboration of several stakeholders, including legal, public health and human rights experts and representatives of people living with HIV. It was seen as a major step forward for the rights of people living with HIV. Stigma Associated with Disease Essay
Restrictions on entry, travel and stay
As of September 2015, 35 countries have laws that restrict the entry, stay and residence of people living with HIV. In 2015, Lithuania became the most recent country to remove such restrictions.39
As of 2015, 17 countries will deport individuals once their HIV positive status is discovered, five have a complete entry ban on people living with HIV and four require a person to be able to prove they are HIV negative before being granted entry.40
Deportation of people living with HIV has potentially life-threatening consequences if they have been taking HIV treatment and are deported to a country that has limited treatment provision. Alternatively, people living with HIV may face deportation to a country where they would be subject to even further discrimination – a practice that could contravene international human rights law.41
Healthcare professionals can medically assist someone infected or affected by HIV, and also provide life-saving information on how to prevent it.42However, HIV-related discrimination in healthcare remains an issue and is particularly prevalent in some countries. It can take many forms, including mandatory HIV testing without consent or appropriate counselling. Health providers may minimise contact with, or care of, patients living with HIV, delay or deny treatment, demand additional payment for services and isolate people living with HIV from other patients. Stigma Associated with Disease Essay
For women living with HIV, denial of sexual and reproductive health and rights services can be devastating. For example, 37.7% of women living with HIV surveyed in 2012 in a six-country study in the Asia–Pacific region reported being subjected to involuntary sterilisation.44
Healthcare workers may violate a patient’s privacy and confidentiality, including disclosure of a person’s HIV status to family members or hospital employees without authorisation.45 Studies by WHO in India, Indonesia, the Philippines and Thailand found that 34% of respondents reported breaches of confidentiality by health workers.46
People from key affected populations may face additional discrimination in healthcare settings. Discriminatory attitudes held by health providers may also lead them to make judgements about a person’s HIV status, behaviour, sexual orientation or gender identity, leading individuals to be treated without respect or dignity. These views are often fuelled by ignorance about HIV transmission routes among healthcare professionals.47
Case study: Reducing stigma and discrimination among healthcare workers in Thailand
In 2012, half of all people living with HIV in Thailand were starting treatment very late and had CD4 counts under 100. HIV stigma was identified as a major barrier to service uptake so health authorities set a target to cut HIV-related stigma and discrimination by 50% by 2016. Stigma Associated with Disease Essay
The Ministry of Public Health found that over 80% of healthcare workers had at least one negative attitude to HIV, while roughly 20% knew colleagues who were unwilling to provide services to people living with HIV or provided them substandard services.49
More than half of respondents reported using unnecessary personal protection measures such as wearing gloves when interacting with people living with HIV. 25% of people living with HIV surveyed said that they avoided seeking healthcare for fear of disclosure or poor treatment, while a third had their status disclosed without their consent.50
In response to these findings, the Ministry of Public Health, in collaboration with civil society and international partners developed initiatives to sensitise healthcare workers in both clinical and non-clinical settings.51
Early results in 2014 indicated that improving the attitude of healthcare workers doesn’t just improve care for people living with HIV but has wider societal benefits as they are seen as role models Stigma Associated with Disease Essay
As of 2017, Thailand had collected data from 22 provinces. The Thai Ministry of Public Health is rolling out an accelerated system-wide stigma reduction programme, in collaboration with civil society and concerned communities.53
A study of health providers in urban health facilities in India found 55-80% of providers displayed a willingness to prohibit women living with HIV from having children, endorsed mandatory testing for female sex workers (94-97%) and stated that people who acquired HIV through sex or drugs “got what they deserved” (50-83%).54
These experiences may leave people living with HIV and people from key affected populations too afraid to seek out healthcare services, or be prevented from accessing them – for instance, if a nurse refuses to treat a sex worker after finding out about their occupation. It also prevents many people from key affected populations being honest with healthcare workers if they’re a sex worker, have same-sex relations, or inject drugs, meaning they are less likely to get services that could help them.55
When I visited a VCT [voluntary counseling and testing] clinic, health personnel were not polite and immediately asked me if I was a sex worker. A doctor asked me outright, ‘Are you HIV positive?’ This discouraged me from going to the clinics.
– Payal, 18, Nepal 56
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In the workplace, people living with HIV may suffer stigma from their co-workers and employers, such as social isolation and ridicule, or experience discriminatory practices, such as termination or refusal of employment.57
Evidence from the People Living with HIV Stigma Index suggests that, in many countries, HIV-related stigma and discrimination are as frequently or more frequently a cause of unemployment or a denial of work opportunity as ill health.58
Key findings from people living with HIV in nine countries across four regions in 2012 found that, as a result of their HIV status, between between 8% (Estonia) and 45% (Nigeria) of respondents had lost their job or source of income; between 5% (Mexico) and 27% (Nigeria) were refused the opportunity to work, and between 4% (Estonia) and 28% (Kenya) had the nature of their work changed or had been refused promotion. In addition, 8% of respondents in Estonia to 54% in Malaysia reported discriminatory reactions from employers once they were aware of the employee’s HIV status. Similarly, 5% in Estonia to 54% in Malaysia reported discriminatory reactions from co-workers who became aware of their colleague’s HIV status.59 Stigma Associated with Disease Essay
It is always in the back of your mind, if I get a job, should I tell my employer about my HIV status? There is a fear of how they will react to it. It may cost you your job, it may make you so uncomfortable it changes relationships. Yet you would want to be able to explain about why you are absent, and going to the doctors.
– HIV-positive woman, UK 60
By reducing stigma in the workplace (via HIV and AIDS education, offering HIV testing, and contributing towards the cost of ARVs) employees are less likely to take days off work, and be more productive in their jobs. This ensures people living with HIV are able to continue working.61
Community and household level stigma
Community-level stigma and discrimination towards people living with HIV can force people to leave their home and change their daily activities.
In many contexts, women and girls often fear stigma and rejection from their families, not only because they stand to lose their social place of belonging, but also because they could lose their shelter, their children, and their ability to survive. The isolation that social rejection brings can lead to low self-esteem, depression, and even thoughts or acts of suicide.62 Stigma Associated with Disease Essay
The International Center for Research on Women (ICRW) reports that in Bangladesh more than half of women living with HIV have experienced stigma from a friend or neighbour and one in five feel suicidal. In the Dominican Republic, six out of ten women living with HIV fear being the subject of gossip, while in Ethiopia, more than half of all women living with HIV report having low self-esteem.63
They [my family] were embarrassed and didn’t want to talk to me. My mother essentially said, ‘Good luck, you’re on your own.’
– Shana Cozad from Tulsa, USA, on her family’s reaction after she tested positive for HIV.64
A survey of married HIV-positive women (15–29 years) in India found 88% of respondents experienced stigma and discrimination from their family and community. Women with older husbands and from household’s with lower economic status were significantly more likely to experience stigma and discrimination from their husbands’ family as well as from friends and neighbours.65 Stigma Associated with Disease Essay
Stigma and discrimination can also take particular forms within community groups such as key affected populations.
For example, studies have shown that within some lesbian, gay, bisexual, transgender and intersex (LGBTI) communities there is segregation between HIV-positive and HIV-negative people, where people associate predominately with those of the same status.66 67
Ending HIV stigma and discrimination
The use of specific programmes that emphasise the rights of people living with HIV is a well-documented way of eradicating stigma. As well as being made aware of their rights, people living with HIV can be empowered in order to take action if these rights are violated.68
Ultimately, adopting a human rights approach to HIV and AIDS is in the public’s interest. Stigma blocks access to HIV testing and treatment services, making onwards transmission more likely. The removal of barriers to these services is key to ending the global HIV epidemic.69
In March 2016, UNAIDS and WHO’s Global Health Workforce Alliance launched the Agenda for Zero Discrimination in Healthcare. This works towards a world where everyone, everywhere, is able to receive the healthcare they need with no discrimination, in line with The UN Political Declaration on Ending AIDS.70 Zero discrimination is also at the heart of the UNAIDS vision, and one of the targets of its Fast-Track response. This focuses on addressing discrimination in healthcare, workplace and education settings.
The School of Nursing has a formal contract with Supporting Families in Mental Illness, Taranaki, to provide learning experiences based on the sharing of narratives by those who have experience with mental health and/or addiction issues, on five separate occasions, during the second year of study in the Bachelor of Nursing programme. Stigma Associated with Disease Essay
Participants share their lived experience in relation to the mental health case study topics, which include depression, psychosis, bipolar affective disorder, alcohol and others drugs and suicide. An array of issues are discussed, including the qualities and attributes of what makes a good nurse, from the perspective of a person receiving care and navigating the ‘system’.
This learning style is unique to the WITT nursing degree and allows us to continuously develop the students’ holistic thinking, as opposed to delivering a segregated mental health paper; this fits with the WITT BN graduate being ‘work ready’, regardless of the context of future employment.
One of the assessments for year 2 students is to write an essay that answers the question, “Is stigma and discrimination still part of society’s behaviour?”; a selection of essays are then forwarded to the Supporting Families team, who award a special prize to the winning essay, which is presented at Graduation. Stigma Associated with Disease Essay
In the build up to celebrating Mental Health Awareness week on October 8 a selection of these essays will be shared each week.
Two of the students whose essays are being published in WITT News have asked that their names not be attached. Those two essays are published below.
IS STIGMA AND DISCRIMINATION STILL PART OF SOCIETY’S BEHAVIOUR?
Two major factors that impact the quality of life [QOL] for people with mental illness [MI] are stigma and discrimination. These issues are problems that have existed on a global level throughout history (Fernando, 2010). Throughout this essay, a critical analysis will take place on the degree of stigma and discrimination that still exists in society today. The approach to this topic will take a unique direction, as Māori mental health [MH] and the impact of generational trauma will be analysed in respect to New Zealand’s [NZ] unique bicultural society. Māori continue to be significantly over-represented in MH statistics and frequently experience stigma and discrimination from both the public and the healthcare system (O’Brien, 2017). In respect to this, interventions to reduce stigma will be discussed from both a nursing and public perspective, and the effectiveness of these interventions will be considered through the analysis of evidence-based literature.
To analysis stigma and discrimination, it is important to understand these words when applied to MH. Stigma is a judgement that deems an individual to be unworthy or dangerous. People who possess stigmatising beliefs often avoid socially interacting with mental health consumers [MHC] as they believe they are unpredictable or not worthy of respect (Fernando, 2010). Stigma Associated with Disease Essay When stigmatising beliefs translate into action, this becomes discrimination. Both have the potential to significantly impact a person’s QOL when experiencing MI. Additionally, the existence of stigmatising beliefs can often generate self-stigmatising beliefs. Self- stigma is an internalised, negative connotation based on the attitudes that exist within society (Fernando, 2010).
From a macro perspective, the NZ government has recently recognised the need to reform MH services so that anti-discriminatory care is prioritised. This aim forms the basis for the Ministry of Health’s Mental Health and Addiction Workforce Action Plan. This five-year plan addresses the impact of trauma on the MH of Māori and highlights discrimination and stigma as barriers to recovery.
This is critical for NZ, as trauma-informed care has the potential to comprehend the generational trauma experienced by Māori following colonisation (Ministry of Health, 2018). Interestingly, reducing discrimination for indigenous MHC was not always a priority for NZ. In 2007, the United Nations [UN] presented the Declaration on Rights of Indigenous People. Of all states, NZ was one of four that voted against this declaration. However, since the signing of this declaration, NZ has reversed their position and now acts in support of it (United Nations, 2008). Stigma Associated with Disease Essay
On a micro level, acknowledging the role of trauma can have a significant impact on the existence of self-stigma. In a Mental Health Foundation (NZ) endorsed study, participants described acknowledging the role of trauma as a predisposing factor for MI and contributed this to self-stigma. This was due to feelings of hopelessness and feeling as if there were too many barriers in place to realise their potential (Peterson, Barnes, & Duncan, 2008). In contrast to this, Bulanda and Byro-Johnson (2016), highlight that recognising the role of trauma on MI could be empowering, decreasing self-stigma. Being given a MI diagnostic label for trauma survivors (including generational trauma) can instil hope and a sense recovery, making MI more manageable by removing any sense of self-blame. Stigma Associated with Disease Essay
From a nursing perspective, legal issues can create contradicting implications. A legal factor that contributes society’s existing stigmatising beliefs is the Mental Health Act (1992). The Act aims to ensure vulnerable, unwell patients can receive care that reduces the potential for harm being caused to themselves or others. Supporters of this Act believe compulsory treatment can be given in a way that upholds the rights of the MHC and provides treatment through the safest course of action (Burgess, 2012). There are both positive and negative implications associated with this Act. However, unfortunately this Act reinforces the negative undertones that many possess about MHCs, such as that they are unfit to make their own decisions, and pose a threat to public safety (O’Brien, 2017).
One ethical dilemma that is associated with involuntary treatment is loss of autonomy. For an ethically educated nurse, this loss of patient autonomy could cause moral distress as the nurse is witness to the loss of freedom of the client, but is bound to follow through with treatment due to the legalities of the Act (Eren, 2014). To overcome this, nurses need to conduct their practice with a high degree of professionalism to ensure the wellbeing of the client. Professionalism is an essential component needed to object the stigma and discrimination that exists within society and the healthcare system. The Nursing Council of New Zealand’s [NCNZ] Code of Conduct (2012), states nurses should act in a way that does not discriminate the individuality of a patient. This should be done by acting with integrity, and placing respect for the patient at the forefront of decisions. To do this reflection should take place on how personal beliefs may impact on nursing care. Stigma Associated with Disease Essay
A specific nursing consideration in NZ is the over-representation of Māori in MH statistics. Prior to colonisation, and the introduction of the biomedical framework, Māori had low rates of MI and used traditional healing practices to treat physical and mental ailments. In the past, the use of traditional healing practices to treat illness was highly discriminated against (Durie, 2009). This can be seen through the introduction of the Tohunga Suppression Act (1907) that criminalised the use of spiritual tohunga practices. Although repealed in 1964, this disregarded the wisdom of Māori and their approach to Māori illnesses. The integration of Māori practices into the mainstream health service is a requirement of the Treaty of Waitangi, as Māori health practices are considered a taonga (Wilson & Haretuku, 2015).
Through analysing the epidemiology of Māori MI, it has been recognised that the Māori population has seen an increase in treatment by 72% in the last sixteen years. This is comparable to 36% for the Pākehā population. Interestingly, this is also noticeable in the rates of access to service of 6.1% of Māori, compared to 3% of non-Māori (Ministry of health, 2017). When analysing these statistics it is important to incorporate social factors that may have contributed to these rates. In a NZ Ministry of Social Development study, changes to socio-economic factor in the last twenty years were associated with significant health determinants. For example, benefit cuts in the late 1990s, increased the equality gap for low socioeconomic New Zealanders. This has resulted in an estimated one million people living in hardship. Changes to society can clearly be associated with increased levels deprivation, exposing the most vulnerable to increased MI risk (Casswell, Huakau, Howden-Chapman & Perry, 2011).
It is also important to consider the role of epigenetics and neurobiology, and how this can impact on a person’s MH. In a review of two studies undertaken on colonised populations, similar results were yielded, suggesting that the existence of generational trauma caused a significant methylation change in the genes that process the body’s stress response (Walters, Mohammed, Evans-Campbell, Beltrán, Chae & Duran, 2011; Verny, 2016). Trauma can also alter the function of the neuroendocrine system, which can have significant impacts on a person’s health. Alterations in cortisol levels and gene methylation changes the body’s adaptive responses and caused overactivation of the sympathetic nervous system. This overactivation, and the neurobiological impacts of stress could significantly alter neurodevelopment, hypothalamic-pituitary-adrenal axis function and the incidence of chronic MI (Walters et al., 2011; Verny, 2016).
Recognising the scientific implications that contribute to the onset of MI is important for destabilising stigmatising beliefs (O’Brien, 2017). Throughout undergraduate nursing study, there has been significant changes in the way MI is viewed. Past perceptions on MHC were based on media portrayals and the sentiments echoed by older family members. This created stigmatising beliefs based on fear and uncertainty, and eventually led to an outright avoidance of MHC. Stigma Associated with Disease Essay
Even more damaging, was the views that existed about the Māori MHC population. The perception of this population was influenced by an attitude of victim blaming and non-existent acknowledgement for the role of colonisation. This lead to a complete disregard on the effect trauma on current Māori realities. Reflecting on past views is a confronting process met with guilt and shame. However, through the power of knowledge this shame can be transferred into a proactive commitment to dedicate oneself to safe MH care as a future Registered Nurse.
The most significant professional growth that has taken place during undergraduate nursing study has been through contact-based learning. This evidence-based approach has incorporated classroom sessions with MH consumers and placements within a MH service. Bingham and O’Brien (2018), describe the positive changes that take place surrounding student’s stigmatising beliefs when guided through contact-based experiences. It was recognised that the beliefs held about MHSC contributed to high levels of anxiety in the clinical situation, hindering learning experiences. However, through careful guidance and exposure to lived-experiences, positive changes can be seen in student nurse’s beliefs and attitudes (Bingham & O’Brien, 2018). Stigma Associated with Disease Essay
An unexpected finding from contact-based intervention was the MHC’s experience of discrimination by the healthcare workforce. Participants in the lived-experience program reported that when this occurred, feelings of helplessness and distrust in the healthcare system developed. An example of this was seen through the reflection from a female client. The client reported that when seeking help for their MI issues they were accused of attention-seeking. This resulted in the client feeling as if they had been shunned from the system and led to them seeking relief from alcohol and drugs. As expected, this resulted in a further deterioration of the client’s MH. It is disappointing to consider that if that client had been treated with dignity and respect, their recovery path would have been more empowering and with greater satisfaction.
Discrimination within the MH system significantly contributes to disengagement from the service and poor MH outcomes. Because of this, positive health experiences greatly rely on the nurse-patient relationship. Clients with past negative experiences with the healthcare system, are more likely to hold self- protective barriers, effecting verbal and non-verbal communication (Sewell, 2009). Leininger’s (1991) Transcultural Care Theory states nurse-client relationships should be based respect for the individuality of the client. For effective communication, nurses should have an appreciation for the client’s needs and the barriers that exist in that person’s health care journey. Stigma Associated with Disease Essay
Eliminating stigma has been identified as a priority to improve the quality of life for MH service users. Recently, there has been a drive to raise awareness about the stigma and discrimination faced by MH consumers (Ministry of Health, 2018). One public awareness program is Mike King’s internationally acclaimed Nutters Club. This movement is based on peer support and the sharing of personal life stories. By utilising social media, Mike King and guests invite discussion about the journey of MI and barriers to recovery. By sharing stories from ordinary New Zealanders, this health promotion model is striving to raise awareness, remove fear and address the stigma that surrounds the MI recovery process (The Key to Life, 2016). Stigma Associated with Disease Essay
In a study undertaken by Livingston, Tugwell, Korf-Uzan, Cianfrone and Coniglio (2012), a similar campaign was evaluated for effectiveness of stigma reduction on the Canadian population. Interestingly, following analysis of surveys undertaken prior [T1] and post [T2] exposure to the campaign, the desired outcome of the campaign was not achieved. When the attitudes towards MI were compared from T1 and T2 surveys, there was no changes in stigmatising beliefs. Although levels of stigma remained unchanged, respondents reported that the campaign has inspired discussion about MI within social circles. In this way, it could be concluded that social campaigns could create a greater awareness of MI, instead of a reduction of stigma (Livingston et al., 2012). As attitudes towards MI are influenced by multiple factors, it would be of interest to conduct further research on NZ’s response to public awareness campaigns.
Equally important as awareness, is the importance of offering a culturally safe environment so clients feel comfortable to access MH services. This should include showing acceptance towards NZ’s bicultural health practices. When working within a biomedical framework it is easy to dismiss the validity of traditional healing practices and alternative medicine. This is because some disregard this form of medicine as non-evidence based and discriminate its use (Wintrob, 2009). In recent years, there has been a resurgence in traditional Māori health practices within the MH system. From this there has been a growth in the understanding of cultural safety and the effectiveness of treating Māori illness with a Māori worldview (Wilson & Hickey, 2015). Through recognising the need for Māori psychotherapy in practice, nurses strive to offer a safe space for the recovery from generational trauma (Rigby, 2017). Stigma Associated with Disease Essay
The stigma and discrimination that people experience, and especially Māori, when accessing MH services still exist despite the great drive from society to change this. Although, progress has been made in recent years, it is more of a question of has NZ become more tolerant and accepting, rather than removed stigma and discrimination? As discussed in this essay, Māori continue to be over-represented in the majority of MH statistics, and experience a high level of stigma. It will take a combined effort from both healthcare services and society to overcome this. However, by gaining an understanding on the generational trauma that exists for Māori, progress can be made to create a society that treats all with greater respect and understanding. Stigma Associated with Disease Essay
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