Mitchell G. Weiss

Health-Related Stigma: Rethinking Concepts and Interventions

Abstract As a feature of many chronic health problems, stigma contributes to a hidden burden of illness. Health-related stigma is typically characterized by social disqualification of individuals and populations who are identified with particular health problems. Another aspect is characterized by social disqualification targeting other features of a persons identity—such as ethnicity, sexual preferences or socio-economic status—which through limited access to services and other social disadvantages result in adverse effects on health. Health professionals therefore have substantial interests in recognizing and mitigating the impact of stigma as both a feature and a cause of many health problems. Rendering historical concepts of stigma as a discrediting physical attribute obsolete, two generations of Goffman-inspired sociological studies have redefined stigma as a socially discrediting situation of individuals. Based on that formulation and to specify health research interests, a working definition of health-related stigma is proposed. It emphasizes the particular features of target health problems and the role of particular social, cultural and economic settings in developing countries. As a practical matter, it relates to various strategies for intervention, which may focus on controlling or treating target health problems with informed health and social policies, countering the disposition of perpetrators to stigmatize, and supporting those who are stigmatized to limit their vulnerability and strengthen their resilience. Our suggestions for health studies of stigma highlight needs for disease- and culture-specific research that serves the interests of international health.

Explanatory Model Interview Catalogue (EMIC): Framework for Comparative Study of Illness

The Explanatory Model Interview Catalogue (EMIC) refers to a collection of locally adapted explanatory model interviews rooted in a common framework. Efforts to develop the EMIC were motivated by research experience in cultural psychiatry and tropical medicine that demonstrated a need to integrate epidemiological and anthropological research methods more effectively. Various adaptations of the EMIC framework have produced semi-structured interviews based on an operational formulation of an illness explanatory model that systematically clarifies the experience of illness from the point of view of the people who are directly affected. Patterns of distress, perceived causes, preferences for help seeking and treatment, and general illness beliefs constitute a framework for the operational formulation of the illness explanatory model. Data sets generated from these EMIC interviews typically include quantitative variables and qualitative prose, which are cross-referenced for analysis to clarify key features and answer important questions about illness experience and its practical implications. This review discusses the development and structure of the EMIC, the adaptation of particular explanatory model interviews, the analysis of data obtained from these interviews, the scope of research they have addressed, and next steps in the development of the EMIC.

Methods of suicide: international suicide patterns derived from the WHO mortality database

OBJECTIVE Accurate information about preferred suicide methods is important for devising strategies and programmes for suicide prevention. Our knowledge of the methods used and their variation across countries and world regions is still limited. The aim of this study was to provide the first comprehensive overview of international patterns of suicide methods. METHODS Data encoded according to the International Classification of Diseases (10th revision) were derived from the WHO mortality database. The classification was used to differentiate suicide methods. Correspondence analysis was used to identify typical patterns of suicide methods in different countries by providing a summary of cross-tabulated data. FINDINGS Poisoning by pesticide was common in many Asian countries and in Latin America; poisoning by drugs was common in both Nordic countries and the United Kingdom. Hanging was the preferred method of suicide in eastern Europe, as was firearm suicide in the United States and jumping from a high place in cities and urban societies such as Hong Kong Special Administrative Region, China. Correspondence analysis demonstrated a polarization between pesticide suicide and firearm suicide at the expense of traditional methods, such as hanging and jumping from a high place, which lay in between. CONCLUSION This analysis showed that pesticide suicide and firearm suicide replaced traditional methods in many countries. The observed suicide pattern depended upon the availability of the methods used, in particular the availability of technical means. The present evidence indicates that restricting access to the means of suicide is more urgent and more technically feasible than ever.

Cultural epidemiology: An introduction and overview

Although the value of interdisciplinary collaboration between epidemiology and anthropology is both widely acknowledged and hotly contested, effective international health policy and multicultural health programmes require it. The EMIC framework for cultural studies of illness was developed in response to such needs, and a cultural epidemiology emerged from that framework as an interdisciplinary field of research on locally valid representations of illness and their distributions in cultural context. These representations are specified by variables, descriptions, and narrative accounts of illness experience, its meaning, and associated illness behaviour. Specialized interactive qualitative and quantitative research methods provide a descriptive account, facilitate comparisons, and clarify the cultural basis of risk, course, and outcomes of practical significance for clinical practice and public health. This paper discusses the theoretical underpinnings of cultural epidemiology and an operational formulation for examining patterns of distress, perceived causes, and help-seeking. Five additional papers in this special issue of Anthropology and Medicine indicate how the EMIC has been used and has engendered an ethnographically grounded cultural epidemiology. Although this overview and these papers are concerned exclusively with mental health, a complementary stream of active research on leprosy, tuberculosis, epilepsy, and other tropical infectious, neurological, and medical disorders is ongoing. Next steps for cultural epidemiology in mental health research are discussed, including (1) further clinic-based studies of psychiatric disorders, (2) studies of deliberate self-harm in clinic and community settings, (3) complementary cultural components of psychiatric epidemiological surveys, (4) baseline assessments to guide community programmes, and (5) contributions to intervention studies.

Stigma interventions and research for international health

The stigma of many diseases and disorders prevalent in the world today is cause for increasing public health concern raising the question of whether new research is necessary before enlightened health policies can be implemented. Because stigma is a very broad topic it is important to acknowledge distinctive features of healthrelated stigma and the social burden of illness. We have formulated a definition of health-related stigma: a social process or related personal experience characterised by exclusion rejection blame or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group identified with a particular health problem. The judgment is medically unwarranted with respect to the health problem itself just as stigma targeting other aspects of group identity (such as race or sexual orientation) is also unwarranted and may adversely affect public health policy and individual health status. (excerpt)

Stigma and the Social Burden of Neglected Tropical Diseases

In a village in Uganda where onchocerciasis is endemic, a 25-year-old woman responded to questions about a photograph of a skin lesion presented with the story of a villager suffering from characteristic dermatitis. She described her communitys experience as follows: “They are hiding their skin so that people cannot see them. I have not heard of anyone who wants others to know about it. No one will allow them to lead, and many people ignore them. They are considered dangerous. People fear contact with them. I feel sorry for them. Even me, I feared that from staying and meeting them we could get the disease … They find it hard to marry, and marriages can break because of this condition.”

Somatization revisited: diagnosis and perceived causes of common mental disorders.

The assessment of somatoform disorders is complicated by persistent theoretical and practical questions of classification and assessment. Critical rethinking of professional concepts of somatization suggests the value of complementary assessment of patients’ illness explanatory models of somatoform and other common mental disorders. We undertook this prospective study to assess medically unexplained somatic symptoms and their patient-perceived causes of illness and to show how patients’ explanatory models relate to professional diagnoses of common mental disorders and how they may predict the short-term course of illness. Tertiary care patients (N = 186) with prominent somatoform symptoms were evaluated with the Structured Clinical Interview for DSM-IV, a locally adapted Explanatory Model Interview to elicit patients’ illness experience (priority symptoms) and perceived causes, and clinical self-report questionnaires. The self-report questionnaires were administered at baseline and after 6 months. Diagnostic overlap between somatoform, depressive, and anxiety disorders occurred frequently (79.6%). Patients explained pure somatoform disorders mainly with organic causal attributions; they explained pure depressive and/or anxiety disorders mainly with psychosocial perceived causes, and patients in the diagnostic overlap group typically reported mixed causal attributions. In this last group, among patients with similar levels of symptom severity, organic perceived causes were related to a lower physical health sum score on the MOS Short Form, and psychosocial perceived causes were related to less severe depressive symptoms, assessed with the Hospital Anxiety and Depression Scale at 6 months. Among patients meeting criteria for comorbid somatoform with anxiety and/or depressive disorders, complementary assessment of patient-perceived causes, a key element of illness explanatory models, was related to levels of functional impairment and short-term prognosis. For such patients, causal attributions may be particularly useful to clarify clinically significant features of common mental disorders and thereby contribute to clinical assessment.

Cultural models of diarrheal illness: Conceptual framework and review

Health planning for diarrheal diseases must be responsive to both epidemiological patterns and local perceptions of health, illness and need. A conceptual framework that relates patterns of distress, explanatory models, help seeking and treatment practices to knowledge and use of oral rehydration therapy (ORT), dietary management, other specific treatments and health policy issues provides the basis for our review of research on diarrheal illness-related beliefs and practices. The ethnomedical model asserts that efforts to secure the compliance of target populations are likely to be inadequate without an alliance between health professionals and communities to identify and address mutually comprehensible objectives that are perceived locally as meaningful and relevant. An appreciation of local cultural models and the diversity of cultural contexts enables health professionals to (1) recognize the significance of local perceptions of diarrheal illness with respect to pertinent outcomes and perceived needs, (2) develop ways to introduce recommendations that communities will accept, and (3) make appropriate use of existing community resources representing local traditions. An agenda for needed research concludes the review.

Traditional community resources for mental health: a report of temple healing from india

The use of complementary medicine and the traditional medicine of other cultures has been increasing in Europe and North America.3 Although less well documented, the use of complementary medicines and consultations with traditional healers is widely acknowledged in low income countries, such as India. Here too the limited availability of health services motivates the use of a wide range of alternative systems of care for various ailments, including mental illnesses4 In addition to herbal and other traditional medicines, healers and healing temples are seen as providing curative and restorative benefits. In India many people troubled by emotional distress or more serious mental illnesses go to Hindu, Muslim, Christian, and other religious centres. The healing power identified with these institutions may reside in the site itself, rather than in the religious leader or any medicines provided at the site. Studies of these healing sites have focused primarily on ethnographic accounts.5 Research has not systematically examined the psychiatric status of the people coming for help at these religious centres or the clinical impact of healing. It has focused primarily on possession and non-psychotic disorders, rather than serious psychotic illnesses. Yet people with serious psychotic illnesses do visit such healing temples in India,6 and understanding the role of these institutions may help with planning for community mental health services in underserved rural areas. We describe here the work of a Hindu healing temple in South India known as a source of help for people with serious mental disorders. We also tried to measure the clinical effectiveness of religious healing at this site. ### Summary points Traditional community resources, including temple healing practices, are widely used in managing mental illnesses in India This research shows that a brief stay at one healing temple in South India improved objective measures of clinical psychopathology In …

Health seeking and perceived causes of tuberculosis among patients in Manila Philippines.

Summary Inefficient case finding is an important stumbling block to successful control of tuberculosis (TB). Multiple health seeking may account for delayed case finding. Health‐seeking behaviour, health seeking delay, perceived causes, and perceived quality of care related to TB were studied in interviews with 319 sputum smear‐positive TB patients. The patients were treated in 22 governmental health centres of Malabon, a municipality of Metro Manila, Philippines. Only 29% of the respondents had gone first to a health centre after onset of TB‐related symptoms, and more than half (53%) had initially consulted a private doctor. A chest X‐ray was obtained for nearly everyone (97%). Two thirds of the patients (66%) had received a prescription for drugs, and 29% had purchased and taken anti‐TB drugs for at least three weeks before they came to a governmental health centre. Concerning community interactions, 36% said they knew at least one person who had been treated for TB without success. The health seeking delay after symptom onset was relatively short – 64% of the respondents said they went to a health facility within 1 month. Case studies illustrate the rationale for health seeking and explain delayed initiation of appropriate treatment for many patients. Findings underscore the need for and indicate approaches to health communication for improved control of TB. Our findings from interview narratives also suggest that improved interpersonal skills of health centre staff and co‐ordination between the private doctors and the health centres may substantially improve services for TB patients.