Hi, we are Djosy Charles, Leon Moraes, and Lisa Melchior from The Measurement Group LLC, a consulting firm focused on evaluating health, behavioral health, and social services for at-risk and vulnerable populations. We would like to share some thoughts about the Health Stigma and Discrimination Framework, which we recently found useful in the context of evaluating a stigma reduction project.
The Health Stigma and Discrimination Framework focuses on the impacts of stigma as it relates to the intersectionality of race, gender, class, sexual orientation, and occupation. It describes how the process of stigmatization is maintained through five stages: public policy, community, and organizations, as well as interpersonally and individually. The framework illustrates how the stages work together to perpetuate the driving factors and social facilitators that ultimately affect stigma practices and experiences within each of the five stages. This is important because stigma perpetuation can affect incidence of disease, morbidity, mortality, quality of life, and social inclusion.
This framework guided the design and evaluation of the Rise Above Stigma project, an initiative that aimed to bring awareness to stigmas that may act as barriers to behavioral health service access and encourage the utilization of behavioral health services within twelve rural parishes in Louisiana’s Northeast Delta region. This project was conducted by the Northeast Delta Human Services Authority in collaboration with SheRay’s & Associates LLC.
In our evaluation, the framework helped inform qualitative coding and data analysis strategies, providing a system for identifying relationships between stigmatization processes and outcomes. Data were collected from virtual town hall meetings in which stakeholders from each participating parish described their views about stigma, how stigmatization affects access and engagement to behavioral health services, and possible solutions to increasing the availability and uptake of these services. Each town hall meeting was recorded, transcribed, and coded using NVivo software, with codes reflecting domains from framework.
Themes about stigma and behavioral health service access were identified according to the five stages and the areas of drivers and facilitators, stigma “markings”, manifestations, and outcomes within the framework. For example, every time race or gender was presented as a topic in the transcription, it was coded under “Stigma Markings”, “Demographic-related stigmas”, and then into “Race” and “Gender”. This allowed us to examine how race and gender – two demographic identifiers – were related to stigma. While this framework was helpful, it required much attention to detail and discernment about how to accurately code quotes from the transcription. In those instances, it helped to have an extra set of eyes on the coded passages. Nevertheless, a pre-existing framework can help guide the coding of qualitative data for stigma related projects and similar initiatives.
We found it was useful to develop a framework that guided the coding of information into specific categories. Collaborating as a team to define each category was essential so that there was a shared understanding of each theme’s definition.
Not everyone defines stigma in the same way, so it was extremely important for evaluators and stakeholders alike to come to a consensus about the definition of stigma and how it’s manifested within specific communities.
The Health Stigma and Discrimination Framework helps to illustrate the process of stigmatization.
The Rise Above Stigma Mid-Year Evaluation Report documents the successes and challenges of a stigma reduction plan in the Northeast Delta region of Louisiana and can be referenced for future stigma reduction plans.
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