Reducing stigma and discrimination to improve child health and survival in low- and middle-income countries: Promising approaches and implications for future research

Nayar, U.U.; Stangl, A; De Zalduondo, B; Brady, L.M. Journal of Health Communication: International Perspectives, 2015; www.tandfonline.com/doi/abs/10.1080/10810730.2014.930213?url_ver=Z39.88-2...

Stigma and discrimination related to social standing and health can significantly affect child health by impeding or diverting child health and development outcomes and pathways.

Child health literature does not document direct connections between child health and the stigmatisation of either children or their caregivers.

Therefore, this study sought to:

  • identify research on interventions that aimed to reduce stigma and discrimination in order to promote child health and well-being in low- and middle-income countries
  • identify characteristics of interventions that were effective and could produce population-level impact
  • focus primarily on stigma associated with HIV and AIDS and on the indirect effects of stigma that children under 5 may experience because of stigmatising attitudes and actions that directly affect their adult caretakers and community members

Framework

Reducing stigma and discrimination framework

 

This HIV stigma reduction framework was used to highlight six domains that together constitute the stigmatisation process:

  • drivers (fear of infection, lack of awareness of stigma, and prejudice and stereotypes)
  • facilitators (gender and cultural norms, availability of social support services, and protective or punitive laws)
  • intersecting stigmas
  • manifestations of stigma
  • outcomes of stigma
  • impacts of stigma

It distinguishes between experienced stigma and discrimination. Rather than viewing discrimination as the end result of the stigmatisation process, experienced stigma and discrimination are considered manifestations of the stigmatisation process.

Together, drivers and facilitators influence whether a stigma is applied to individuals or groups. Of particular relevance to the child health field are intersecting, or multiple, stigmas that people often face as a result of HIV status, profession, gender, migration, poverty, drug use, marital status and race.

For guidance on understanding and using this framework to design research studies and measure stigma, see STRIVE's technical brief

Other STRIVE resources on stigma include a special issue of the Journal of the International AIDS Society and two Learning Labs:

Findings

The findings are divided into five sections:

HIV-related stigma in the context of prevention of mother to child transmission (PMTCT)

Evidence shows that interventions using a combination of sensitisation and participatory activities can reduce stigma in healthcare and community settings, but few PMTCT programmes have systematically applied these strategies, and no rigorous research has been conducted to measure the impact of these programme enhancements on key PMTCT outcomes, including infant seroconversion and postpartum child survival.

Neonatal survival and health

Studies of interventions that specifically target stigma and discrimination as a means to improve neonatal survival and health are nearly non-existent. PMTCT literature demonstrates that maternal health and newborn outcomes are inextricably linked. Addressing stigma and discrimination at all stages leading up to the newborn’s entry into the world, during delivery and shortly after birth are critical to ensuring survival and good health outcomes among neonates.

Healthy early childhood development

Few studies examine specific strategies to overcome discrimination and stigma that directly affect children’s developmental outcomes, and the studies that do tend not to be empirically strong. However, nearly all efforts to adapt interventions to local contexts, specific cultural groups or family types entail some consideration of issues related to stigma and discrimination. Furthermore, there is moderate evidence that there are interventions targeting HIV stigma that yield positive attitudinal shifts and increased knowledge in families, care providers, and communities, and such changes can serve as the basis for behavioural changes that facilitate children’s physical, cognitive, and social growth.

Nutrition

This review noted the absence of interventions directly or indirectly addressing stigma in the domain of nutrition. They did not identify any studies that specifically addressed the stigmas around childhood nutrition, although they did find intervention on stigmas around food insecurity in broader social and cultural contexts and in gender inequality.

Marginalised groups and child survival

Many interventions to prevent diarrhoea and pneumonia exist within present health systems, but their coverage and availability to poor and marginalized populations varies greatly

Conclusions

It is important to note that interventions directly addressing stigma and discrimination were identified for HIV and not for any of the other listed health conditions.

The child health field would greatly benefit from more research to understand and address stigma as it relates to child health and well-being. The authors suggest applying a framework, adapted from the HIV stigma field, to direct future research. They also recommend the adaptation of existing strategies to reduce HIV-related stigma and discrimination to address social and health-related stigmas affecting children and their families.

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