Stephenie R. Chaudoir

From Conceptualizing to Measuring HIV Stigma: A Review of HIV Stigma Mechanism Measures

Recent analyses suggest that lack of clarity in the conceptualization and measurement of HIV stigma at an individual level is a significant barrier to HIV prevention and treatment efforts. In order to address this concern, we articulate a new framework designed to aid in clarifying the conceptualization and measurement of HIV stigma among individuals. The HIV Stigma Framework explores how the stigma of HIV elicits a series of stigma mechanisms, which in turn lead to deleterious outcomes for HIV uninfected and infected people. We then apply this framework to review measures developed to gauge the effect of HIV stigma since the beginning of the epidemic. Finally, we emphasize the utility of using three questions to guide future HIV stigma research: who is affected by, how are they affected by, and what are the outcomes of HIV stigma?

Living With a Concealable Stigmatized Identity: The Impact of Anticipated Stigma, Centrality, Salience, and Cultural Stigma on Psychological Distress and Health

The current research provides a framework for understanding how concealable stigmatized identities impact peoples psychological well-being and health. The authors hypothesize that increased anticipated stigma, greater centrality of the stigmatized identity to the self, increased salience of the identity, and possession of a stigma that is more strongly culturally devalued all predict heightened psychological distress. In Study 1, the hypotheses were supported with a sample of 300 participants who possessed 13 different concealable stigmatized identities. Analyses comparing people with an associative stigma to those with a personal stigma showed that people with an associative stigma report less distress and that this difference is fully mediated by decreased anticipated stigma, centrality, and salience. Study 2 sought to replicate the findings of Study 1 with a sample of 235 participants possessing concealable stigmatized identities and to extend the model to predicting health outcomes. Structural equation modeling showed that anticipated stigma and cultural stigma were directly related to self-reported health outcomes. Discussion centers on understanding the implications of intraindividual processes (anticipated stigma, identity centrality, and identity salience) and an external process (cultural devaluation of stigmatized identities) for mental and physical health among people living with a concealable stigmatized identity.

The Disclosure Processes Model: Understanding Disclosure Decision Making and Postdisclosure Outcomes among People Living with a Concealable Stigmatized Identity.

Disclosure is a critical aspect of the experience of people who live with concealable stigmatized identities. This article presents the disclosure processes model (DPM)-a framework with which to examine when and why interpersonal disclosure may be beneficial. The DPM suggests that antecedent goals representing approach and avoidance motivational systems moderate the effect of disclosure on numerous individual, dyadic, and social contextual outcomes and that these effects are mediated by three distinct processes: (a) alleviation of inhibition, (b) social support, and (c) changes in social information. Ultimately, the DPM provides a framework that advances disclosure theory and identifies strategies that can assist disclosers in maximizing the likelihood that disclosure will benefit well-being.

HIV Stigma Mechanisms and Well-Being among PLWH: A Test of the HIV Stigma Framework

The current work evaluates the HIV Stigma Framework in a sample of 95 people living with HIV recruited from an inner-city clinic in the Bronx, NY. To determine the contributions of each HIV stigma mechanism (internalized, enacted, and anticipated) on indicators of health and well-being, we conducted an interviewer-delivered survey and abstracted data from medical records. Results suggest that internalized stigma associates significantly with indicators of affective (i.e., helplessness regarding, acceptance of, and perceived benefits of HIV) and behavioral (i.e., days in medical care gaps and ARV non-adherence) health and well-being. Enacted and anticipated stigma associate with indicators of physical health and well-being (i.e., CD4 count less than 200 and chronic illness comorbidity respectively). By differentiating between HIV stigma mechanisms, researchers may gain a more nuanced understanding of how HIV stigma impacts health and well-being and better inform targeted interventions to improve specific outcomes among people living with HIV.ResumenEl presente trabajo evalúa el Marco Teórico del Estigma hacia el VIH en una muestra de 95 personas que viven con VIH y que fueron reclutadas en una clínica del centro de la ciudad del Bronx, NY. Para determinar la contribución de cada mecanismo con el que el estigma hacia el VIH (interiorizado, percibido, y anticipado) funciona en relación a indicadores de salud y bienestar, se realizó una encuesta conducida por entrevistadores y se extrajo información de registros médicos. Los resultados sugieren que el estigma internalizado se asocia significativamente con indicadores de salud y bienestar afectivos (es decir desesperanza, aceptación del VIH y beneficios percibidos por tener VIH) y de comportamiento (es decir, días de interrupción en la atención médica y falta de adherencia a medicamentos ARV). El estigma percibido y el anticipado se asocian con indicadores de salud física y bienestar (es decir, recuento de CD4 inferior a 200 y comorbilidad con otras enfermedades crónicas, respectivamente). Al diferenciar entre mecanismos de estigmatización en relación al VIH, los investigadores pueden obtener una comprensión más matizada de cómo el estigma impacta a la salud y al bienestar y pueden utilizar esta información para informar adecuadamente el desarrollo de intervenciones dirigidas a mejorar resultados específicos entre las personas que viven con VIH.

Understanding HIV disclosure: A review and application of the Disclosure Processes Model

HIV disclosure is a critical component of HIV/AIDS prevention and treatment efforts, yet the field lacks a comprehensive theoretical framework with which to study how HIV-positive individuals make decisions about disclosing their serostatus and how these decisions affect them. Recent theorizing in the context of the Disclosure Processes Model has suggested that the disclosure process consists of antecedent goals, the disclosure event itself, mediating processes and outcomes, and a feedback loop. In this paper, we apply this new theoretical framework to HIV disclosure in order to review the current state of the literature, identify gaps in existing research, and highlight the implications of the framework for future work in this area.

Death Without God Religious Struggle, Death Concerns, and Depression in the Terminally III

Religious worldviews often provide comfort near the end of life, but they can cause distress if life circumstances are perceived as evidence of Gods disfavor. This study, the first to test terror management theory (TMT) with terminally ill participants, examined the hypothesis that concerns about death mediate the relationship between religious struggle (and religious comfort) and depression in the terminally ill. Ninety-eight patients with end-stage congestive heart failure (CHF) completed measures of religious comfort, religious struggle, belief in an afterlife, concerns about death, and depression. In separate hierarchical linear regression models that controlled for degree of belief in an afterlife, death concerns fully mediated the relationships between religious struggle and depression and between religious comfort and depression. These findings suggest that religious struggle is a breakdown in the terror management system that leaves the individual vulnerable to the terror of death, and that properly functioning religious worldviews offer comfort by buffering the individual against death concerns.

HIV Stigma and Physical Health Symptoms: Do Social Support, Adaptive Coping, and/or Identity Centrality Act as Resilience Resources?

Despite efforts to eliminate it at the societal level, HIV stigma persists and continues to threaten the health of people living with HIV (PLWH). We tested whether social support, adaptive coping, and/or HIV identity centrality act as resilience resources by buffering people from the negative impact of enacted and/or anticipated stigma on stress and ultimately HIV symptoms. Ninety-three PLWH completed a survey, and data analyses tested for evidence of mediation and moderation. Results demonstrated that instrumental social support, perceived community support, and HIV identity centrality buffered participants from the association between anticipated stigma and HIV symptoms. That is, anticipated stigma was associated with HIV symptoms via stress only at low levels of these resources. No resources buffered participants from the impact of enacted stigma. Identifying and enhancing resilience resources among PLWH is critical for protecting PLWH from the harmful effects of stigma.ResumenA pesar de los esfuerzo para eliminar en todos los niveles sociales, el estigma del VIH, este continua amenazando la salud de las personas viviendo con VIH (PLWH). Nosotros examinamos si el soporte social, mecanismos adaptados, y/o la identidad central del VIH actúan como recursos adaptados neutralizando a las personas de impactos negativos y/o anticipando el stress causado por el estigma y el aumento de los síntomas del VIH. Noventa y tres PLHW completaron las encuestas y los resultados fueron examinados para evidencia de mediación y moderación. Los resultados demostraron que el soporte social, el soporte de la comunidad e individualidad central son instrumentales para neutralizar a los participantes de la asociación entre el estigma anticipado y los síntomas del VIH. Esto quiere decir que el estigma anticipado estaba asociado con síntomas del VIH a través del stress solamente en niveles más bajos de estos recursos. Ninguno de los recursos neutralizan a los participantes del impacto de los estigmas establecidos. Es crítico el poder identificar e intensificar los recursos establecidos entre PLWH para protección de PLWH de los efectos dañinos del estigma.

Examining Effects of Anticipated Stigma, Centrality, Salience, Internalization, and Outness on Psychological Distress for People with Concealable Stigmatized Identities

Understanding how stigmatized identities contribute to increased rates of depression and anxiety is critical to stigma reduction and mental health treatment. There has been little research testing multiple aspects of stigmatized identities simultaneously. In the current study, we collected data from a diverse, urban, adult community sample of people with a concealed stigmatized identity (CSI). We targeted 5 specific CSIs – mental illness, substance abuse, experience of domestic violence, experience of sexual assault, and experience of childhood abuse – that have been shown to put people at risk for increased psychological distress. We collected measures of the anticipation of being devalued by others if the identity became known (anticipated stigma), the level of defining oneself by the stigmatized identity (centrality), the frequency of thinking about the identity (salience), the extent of agreement with negative stereotypes about the identity (internalized stigma), and extent to which other people currently know about the identity (outness). Results showed that greater anticipated stigma, greater identity salience, and lower levels of outness each uniquely and significantly predicted variance in increased psychological distress (a composite of depression and anxiety). In examining communalities and differences across the five identities, we found that mean levels of the stigma variables differed across the identities, with people with substance abuse and mental illness reporting greater anticipated and internalized stigma. However, the prediction pattern of the variables for psychological distress was similar across the substance abuse, mental illness, domestic violence, and childhood abuse identities (but not sexual assault). Understanding which components of stigmatized identities predict distress can lead to more effective treatment for people experiencing psychological distress.

Discredited Versus "Discreditable": Understanding How Shared and Unique Stigma Mechanisms Affect Psychological and Physical Health Disparities.

In his classic treatise, Goffman (1963) delineates between people who are discredited—whose stigma is clearly known or visible—and people who are discreditable—whose stigma is unknown and can be concealable. To what extent has research in the past 50 years advanced Goffmans original ideas regarding the impact of concealability on stigma management strategies and outcomes? In the current article, we outline a framework that articulates how stigma can “get under the skin” in order to lead to psychological and physical health disparities. Further, we consider when and to what degree concealability moderates these effects, creating divergent outcomes for the discredited and discreditable.

Coping with HIV Stigma: Do Proactive Coping and Spiritual Peace Buffer the Effect of Stigma on Depression?

Although HIV stigma is a significant predictor of depression, little is known about which factors might most effectively buffer, or attenuate, this effect. We examined whether two coping-related factors—proactive coping and spiritual peace—modified the effect of HIV stigma on likelihood of depression among a sample of 465 people living with HIV/AIDS (PLWHA). In a cross-sectional analysis, we conducted hierarchical logistic regressions to examine the effect of HIV stigma, proactive coping, spiritual peace, and their interactions on likelihood of significant depressive symptoms. Spiritual peace moderated the effect of HIV stigma on depression at high—but not low—levels of HIV stigma. No such effect was observed for proactive coping. Findings suggest that spiritual peace may help counteract the negative effect of HIV stigma on depression. Intervention components that enhance spiritual peace, therefore, may potentially be effective strategies for helping PLWHA cope with HIV stigma.ResumenAunque el estigma del VIH es un predictor significativo de la depresión, se sabe poco sobre los factores que podría resultar más eficaz de atenuar este efecto. Se examinó si los dos factores relacionados con la frente—afrontamiento proactivo y espiritual de la paz—modificó el efecto del estigma del VIH en la probabilidad de depresión en una muestra de 465 personas que viven con el VIH/SIDA (PVVS). En un análisis de corte transversal, se realizó regresión logística jerárquica para examinar el efecto del estigma del VIH, afrontamiento proactivo, la paz espiritual, y sus interacciones sobre la probabilidad de síntomas depresivos significativos. La paz espiritual moderó el efecto del estigma del VIH sobre la depresión en niveles altos de estigma del VIH, pero este efecto no ocurrió en los niveles bajos de estigma del VIH. Sin embargo, este efecto no se observó con el afrontamiento proactivo. Los resultados sugieren que la paz espiritual puede ayudar a contrarrestar el efecto negativo del estigma del VIH en la depresión. Componentes de intervención que mejoren la paz espiritual, por lo tanto, potencialmente pueden ser estrategias eficaces para ayudar a las PVVS hacer frente al estigma del VIH.