Jennifer Stuber

Stigma, prejudice, discrimination and health

There is a great urgency to understand more fully the linkages between stigma, prejudice, discrimination and health to aide in the development of effective public health strategies. A goal of the US Healthy People 2010 programme is to eliminate health disparities among different segments of the population (DHHS, 2002). Prejudice and discrimination are believed to be important contributors to the production of health disparities (IOM, 2002). It is difficult to pick up a consensus report on mental illness or HIV/AIDS without finding numerous references to the ways the stigmatization of these health conditions undercuts prevention and treatment efforts (DHHS, 2003; USAID, 2000). For this reason, in September 2006, the Health & Society Scholars Working Group on Stigma, Prejudice, Discrimination and Health convened scholars across the social and health sciences who study the social and psychological processes of stigmatization and prejudice. The objective of this conference was to strengthen collaboration across disciplines, discuss challenging conceptual issues, and identify the most pressing research objectives facing this relatively new line of inquiry. Driving discussions was the budding idea for a Special Issue that would attempt to bridge disparate research traditions in stigma, on the one hand, and in prejudice and discrimination on the other. As editors of the Special Issue, we believe the importance of this endeavor lies in missed opportunities for conceptual coherence and for capitalizing on insights generated from each research tradition and possibly, to an underestimation of the impact of stigma and prejudice on health. Several exciting manuscripts emerged from the conference making up the content of this Special Issue. The Special Issue breaks from existing volumes in fundamental ways. To date, manuscript collections on stigma and those on prejudice and discrimination are organized around a single disciplinary perspective and focus on either stigma or prejudice but never both. Authors included in the Special Issue write from diverse disciplinary perspectives and represent a starting point of cooperation among scholars interested in these two traditions. The articles develop conceptual and empirical research linking stigma and prejudice; identify under-recognized cultural and policy dynamics that contribute to the formation of stigma and prejudice and may mediate their health impacts; describe pathways through which stigma and prejudice affect health outcomes; and explore the implications of these themes for public health practice. In this commentary, we explain why these themes are important and introduce articles in the Special Issue.

Posttraumatic Stress Disorder in Manhattan, New York City, After the September 11th Terrorist Attacks

Estimates of acute mental health symptoms in the general population after disasters are scarce. We assessed the prevalence and correlates of acute posttraumatic stress disorder (PTSD) in residents of Manhattan 5–8 weeks after the terrorist attacks of September 11, 2001. We used random-digit dialing to contact a representative sample of adults living in Manhattan below 110th Street. Participants were interviewed about prior life events, personal characteristics, exposure to the events of September 11th, and psychological symptoms after the attack. Among 988 eligible adults, 19.3% reported symptoms consistent with PTSD at some point in their life, and 8.8% reported symptoms consistent with a diagnosis of current (within the past 30 days) PTSD. Overall, 57.8% of respondents reported at least one PTSD symptom in the past month. The most common past-month symptoms were intrusive memories (27.4%) and insomnia (24.5%). Predictors of current PTSD in a multivariable model were residence below Canal Street, low social support, life stressors 12 months prior to September 11th, perievent panic attack, losing possessions in the attacks, and involvement in the rescue efforts. These findings can help guide resource planning for future disasters in densely populated urban areas.

Stigma and coercion in the context of outpatient treatment for people with mental illnesses

The policies and institutional practices developed to care for people with mental illnesses have critical relevance to the production of stigma as they can induce it, minimize it or even block it. This manuscript addresses two prominent and competing perspectives on the consequences for stigma of using coercion to insure compliance with outpatient mental health services. The Coercion to Beneficial Treatment perspective (Torrey, E. F., & Zdanowicz, M. (2001). Outpatient commitment: what, why, and for whom. Psychiatric Services, 52(3), 337-341) holds that the judicious use of coercion facilitates treatment engagement, aides in symptom reduction, and, in the long run, reduces stigma. The Coercion to Detrimental Stigma perspective (Pollack, D. A. (2004). Moving from Coercion to Collaboration in Mental Health Sevices DHHS (SMA) 04-3869. In Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration) claims that coercion increases stigmatization resulting in low self-esteem, a compromised quality of life, and increased symptoms. We examine these differing perspectives in a longitudinal study of 184 people with serious mental illness, 76 of whom were court ordered to outpatient treatment and 108 who were not. They were recruited from treatment facilities in the New York boroughs of the Bronx and Queens. We measure coercion in two ways: by assignment to mandated outpatient treatment and with a measure of self-reported coercion. The longitudinal analysis allows stringent tests of predictions derived from each perspective and finds evidence to support certain aspects of each. Consistent with the Coercion to Beneficial Treatment perspective, we found that improvements in symptoms lead to improvements in social functioning. Also consistent with this perspective, assignment to mandated outpatient treatment is associated with better functioning and, at a trend level, to improvements in quality of life. At the same time the Coercion to Detrimental Stigma perspective is supported by findings showing that self-reported coercion increases felt stigma (perceived devaluation-discrimination), erodes quality of life and through stigma leads to lower self-esteem. Future policy needs not only to find ways to insure that people who need treatment receive it, but to achieve such an outcome in a manner that minimizes circumstances that induce perceptions of coercion.

Interpersonal Discrimination and the Health of Illicit Drug Users

Although discrimination has been shown to adversely affect the health of marginalized populations, there is a paucity of research on the health impacts of discrimination experienced by illicit drug users. The purpose of this study was to examine the association between interpersonal discrimination and the mental and physical health of illicit drug users taking into account several potential confounding factors. A sample of 1,008 active illicit substance users (defined as having used cocaine, crack, or heroin in the previous 2 months) were recruited in three New York City neighborhoods between August 2000 and January 2001 using street-outreach techniques. Discrimination due to illicit drug use was the most common form of interpersonal discrimination experienced and more than one-half the study participants reported experiencing discrimination due to more than one attribute. Discrimination was significantly associated with poor mental health (measured by the SF-36 mental health score), depression (measured by the CES-D), and the number of self-reported chronic physical health conditions. The presence of multiple stigmatizing characteristics was associated with poorer mental and physical health. Discrimination may contribute to poor mental and physical health in this marginalized population, potentially complicating the provision of substance abuse treatment.

Stigma and Smoking: The Consequences of Our Good Intentions

Smoking has become increasingly socially unacceptable in the United States, and the change coincides with a decline in tobacco use. This growing social unacceptability raises an important new question: Do people who smoke think they are stigmatized? Stigmas may function as a source of social control, contributing to smokers’ decisions to quit in order to avoid stigmatization and social exclusion. However, smoker‐related stigmas may have counterproductive consequences for smokers if stigmas encourage secrecy and social withdrawal from nonsmokers. This study, based on a random survey of smokers in New York City, provides new measures of perceived devaluation, perceived differential treatment due to smoking, social withdrawal from nonsmokers, and concealment of smoking status. Forty‐four percent perceive devaluation and 17 percent report experiencing differential treatment due to smoking. In short, the results suggest that the stigmatization of smokers is a potentially powerful and unrecognized force, one that may have counterproductive consequences.

Gender disparities in posttraumatic stress disorder after mass trauma

BACKGROUND Although several studies have shown that rates of posttraumatic stress disorder (PTSD) are higher in women than in men, less is known about whether women are more vulnerable to PTSD after a major community-wide traumatic event. OBJECTIVE The aim of this study was to examine gender disparities in the prevalence of probable lifetime PTSD and probable PTSD after a mass traumatic event. METHODS A representative sample of men and women living in the New York City metropolitan area was selected using random-digit dialing, and subjects were interviewed by telephone 6 to 9 months after the September 11, 2001 (9/11) terrorist attacks. We assessed probable lifetime PTSD and probable PTSD related to the 9/11 attacks using a brief screening instrument and potential correlates. RESULTS A total of 2752 individuals (1479 women, 1273 men) were interviewed. The lifetime prevalence of probable PTSD was significantly higher for women than for men (17.2% vs 12.1%; P = 0.005). Experiences of sexual assault (P < 0.001), preexisting mental health problems (P = 0.04), race/ethnicity (P = 0.01), marital status (P < 0.001), and having had probable peri-event panic in the first few hours after the 9/11 attacks (P < 0.001) were all significantly related to womens greater susceptibility to probable lifetime PTSD. However, the prevalence of probable PTSD related to 9/11 was not significantly different between women and men (6.5% vs 5.4%), although women were significantly more likely to report re-experiencing (P < 0.001) and hyperarousal (P < 0.001) symptoms than were men. Women were more likely than men to experience probable peri-event panic during the 9/11 attacks (P < 0.001); this explained, in part, the greater subsequent likelihood of re-experiencing and hyperarousal symptoms among women compared with men. CONCLUSIONS More factors explain the risk of PTSD among women and men after interpersonal trauma than after a disaster. Using peri-event panic symptomatology after a traumatic event to determine the risk of posttraumatic symptoms may suggest avenues for intervention that can decrease the burden of PTSD in women.

Who conceals their smoking status from their health care provider

INTRODUCTION The decline in the social acceptability of tobacco use has the potential consequence that smokers may conceal their smoking from health care providers. METHODS To assess the frequency and correlates of concealing ones smoking status from a health care provider, we analyzed data from the New York Social Environment Study, a cross-sectional random-digit-dialed telephone survey of 4,000 adult New York City residents surveyed between June and December 2005 (cooperation rate = 54%). A total of 835 current smokers were asked if they had ever kept their smoking status a secret from a doctor or another health care provider. Multiple items assessed the social unacceptability of smoking. Other potential correlates of smoking status nondisclosure were demographics, health status, frequency of tobacco use, and dependence. RESULTS Some 8% of respondents (N = 63) reported ever keeping their smoking status a secret from a health provider. Nondisclosure of smoking status was more common among respondents who perceived high compared with low levels of smoker-related stigma (perceptions that they were devalued because they smoke; odds ratio [OR] = 2.83, 95% CI = 1.14-7.01) and among respondents who reported that smoking was not allowed in their home (OR = 2.04, 95% CI = 1.01-4.11) in a multiple logistic regression analysis that adjusted for demographics, health status, frequency of tobacco use, and dependence. No other factors were associated with nondisclosure in this model. DISCUSSION A small percentage of smokers may conceal their smoking status from their health care providers, and those who do are more likely to perceive their tobacco use to be socially unacceptable.

Psychological Impact of Terrorism on Children and Families in the United States

Summary This article reviews the literature on the psychological impact of terrorism on children and families in the United States. It includes studies of the 1993 World Trade Center bombing in New York City and the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, as well as the September 11 attacks. These studies explore the impact of various forms and degrees of exposure to terrorism on children across the development spectrum and on the relationships between parental and child reactions. The article concludes with a framework for future research on childrens adaptation following mass trauma.

Teachers in the aftermath of terrorism: a case study of one New York City school.

Teachers are frequently expected to support children psychologically in the aftermath of mass casualty events, yet they generally have not been trained to do so. This study of a small private school in New York City reports the reactions, needs, and interests in preparedness training among teachers in response to the September 11, 2001, terrorist attacks. By and large, teachers coped by talking to others and/or a health professional, but felt ill-equipped to intervene with students and expressed substantial need for assistance.

An examination of enrollment of children in public health insurance in New York City through facilitated enrollment

A cohort of families was followed through the enrollment process for Medicaid and Child Health Plus in New York City to determine success in enrollment and the time it takes to enroll. Families were recruited into the study by enrollers in community-based organizations and managed-care organizations. In our sample, three of four families were successful in enrolling. On average, it took 60 days to attain insurance. Most applicants (76%) received some sort of assistance from enrollers, most frequently in determining which documents were needed (74%). In a multivariable analysis, some of the factors associated with success in enrollment included being assisted by a community-based facilitated enroller, knowledge of required documents, and baving lost a child’s other bealth insurance.