Download Final updated Stigma Dr Ablah

Running head: STIGMA CONCEPT MATURITY
Maturity of Stigma as a Concept in Nursing Discipline
Laila Al-Daken
Ghadeer al Dweik
Abla Habeeb Allah
Hana' abu Snieneh
Ruba al Ajarmeh
Faculty of Nursing
University of Jordan
1
Stigma a Concept in Nursing Discipline
2
Table of Contents
Abstract ......................................................................................................................................................... 3
Introduction ................................................................................................................................................... 3
Definitions of Stigma ..........................................................................Ошибка! Закладка не определена.
Stigma In Nursing Discipline........................................................................................................................ 4
Methods ...................................................................................................................................................... 10
Findings ...................................................................................................................................................... 10
Epistemological....................................................................................................................................... 10
Logical .................................................................................................................................................... 13
Pragmatical ............................................................................................................................................. 15
Linguistical ............................................................................................................................................. 20
Conclusion .................................................................................................................................................. 21
References ................................................................................................................................................... 22
Stigma a Concept in Nursing Discipline
3
Abstract
Purpose: The purpose of this paper is to evaluate the level of maturity of stigma as a concept in
the nursing discipline.
Method: The four principles of Morse and his colleagues were used to evaluate the Maturity
level of stigma concept: epistemological, logical, pragmatical, and linguistical.
Findings: This evaluation suggests that the concept of stigma is immature, defined
inconsistently, and measured with varied instruments.
Conclusion: Stigma is an important concept for nursing and public health, further development
and clarifications for stigma concept are needed.
Clinical Implication: How stigma is defined can assist the nurse to improve the assessment of
the patients health and to identify patients and their families needs. In addition, the nurse will be
able to increase the public awareness about the stigmatization phenomenon which may influence
positively to change health care policies and public awareness.
Introduction
Nursing concepts are relatively abstract, but they differ in their abstraction level (Waltz,
Strickland, & Lenz, 2010). As a feature of many chronic illnesses; health professionals and the
general population gave more attention toward the concept of stigma. Health professionals
therefore have substantial interests in recognizing and analyzing the impact of stigma as both an
aspect and a cause of many health problems (Weiss, Ramakrishna & Somma, 2006).
The negative influence of stigma on people’s lives creates a negative self-concept and
causes individuals to be socially distance from the society (Parcesepe & Cabassa, 2012). The
concept of stigma has been well documented and is associated with people who suffer from
Stigma a Concept in Nursing Discipline
4
specific health problems as Human Immunodeficiency Virus (HIV), cancer, mental illness, and
disability. Furthermore, ethnic minorities are particularly more vulnerable to stigmatization than
other people (Copel & Al-Mamari, 2015).
How stigma is defined or understood is important for health professionals, patients, and
general population. Literature and research address the influence of stigma towards diseases;
however, systematic conceptual analysis to identify the maturity level of stigma concept is still
lacking (Copel & Al-Mamari, 2015, Parcesepe & Cabassa, 2012).
The purpose of this paper is to evaluate the maturity level of the stigma concept as used in
nursing and health discipline based on the four principles of Morse et al. (1996), epistemological,
logical, pragmatical, and linguistical. This will help nurses and health professionals to
understand the concept of stigma properly.
Definitions of Stigma
Historically, stigma as a term goes back to the ancient Greece where criminals, slaves, and
traitors were identified by using tattoos on their bodies. People with illness or abnormal
behaviors have been socially discriminated and avoided (Engebretson, 2013). Later in Christian
time, the word stigma used for the interpretation of bodily physical features as an indicator either
for holy grace and/or physical disorder (Goffman, 1963). In the past, stigma was used in medical
texts to refer to pathological markings on the skin such as petechia or lesions that are associated
with specific diseases (Weiss, Ramakrishna, & Somma, 2006). The English Oxford dictionary
defined stigma as “Feelings of disapproval that people have about particular illnesses or ways of
behaving” (Oxford Dictionary, 2016).
Stigma a Concept in Nursing Discipline
5
Goffman (1963), who is a well-known sociologist defined stigma as “The phenomenon
whereby an individual with an attribute which is deeply discredited by his/her society is rejected
as a result of the attribute. Stigma is a process by which the reaction of others spoils normal
identity” (Lim & Tan, 2014, p. 2). Goffman considered stigma as a relation between attribute and
stereotype where the stigmatized person is moved from the normal and usual to the deviant and
discounted one, also identified three types of stigma, body (physical), character (personal), and
tribal (social). Goffman’s effort is considered as seminal work and has inspired research on
stigma in social science and social psychology (Omori, Mori, & White, 2014).
Link and Phelan (2001) claimed that as a result of vast increase of social science research
on stigma especially in social psychology, the definition of stigma became too vague and
individualized. As response, they constructed a definition of stigma as “the co-occurrence of its
components–labeling, stereotyping, separation, status loss, and discrimination–and further
indicate that for stigmatization to occur, power must be exercised” (Link & Phelan, 2001, p.
363).
Weiss and colleagues (2006), proposed a formulation of concept of stigma for public
health to enhance action-oriented research on health-related stigma. They defined stigma as “a
social process, experienced or anticipated, characterized by exclusion, rejection, blame, or
devaluation that results from experience or reasonable anticipation of an adverse social judgment
about a person or group” (p. 280).
Stigma a Concept in Nursing Discipline
6
Stigma In Nursing Discipline
Not until 1963 when Erving Goffman described the concept of stigma in his pioneer work
(Stigma: Notes on the Management of Spoiled Identity). He identified Sigma in its social
context as visible and invisible attributes and characteristics in an individual, group, or society
that cause discrediting, devaluation and stereotyping for them (Omori, Mori, & White, 2014). In
2011, Bos, Pryor, Reeder and Stutterheim identified four types of interrelated and integrated
stigma: public stigma, self-stigma, stigma by association, and structural stigma (Bos, Pryor,
Reeder, & Stutterheim, 2013).
Nursing discipline has been concerned with the study of Stigma as a concept. It has been
widely used in nursing research in relation to three domains; psychiatric and mental illness,
infectious diseases such as HIV and Hepatitis C, and in chronic illness such as diabetes (Butt,
2008; Florom-Smith & Santis, 2012; Oliveira, Carvalho, & Esteves, 2016).
Though, it has been over fifty years for the definition of stigma concept by Goffman; the
concept of stigma in nursing literature remains unclear (Florom-Smith & Santis, 2012),
inconsistent, and there is an overlap in conceptual and operational definitions (Oliveira,
Carvalho, & Esteves, 2016; Kato, Takada, & Hashimoto, 2014; Zelaya, Sivaram, Johnson,
Srikrishnan, Suniti, & Celentano, 2012). However, most of nurses based their derived definitions
of Stigma on the seminal work of Goffman (Pinto-Foltz & Logsdon, 2008; Brunton, 1997) .This
indicates lack of a specific nursing definition of stigma concept in nursing.
Some nursing studies have focused on stigma as a general attribute, while other studies
have elaborated on the different types of stigma. Furthermore were inconsistent when they
referred to the types, such as (Oliveira, Carvalho, & Esteves, 2016; Omori, Mori, & White, 2014;
Stigma a Concept in Nursing Discipline
7
Florom-Smith & Santis, 2012). Examples of definitions of Stigma concept in nursing discipline
are presented in Table 1.
Stigma a Concept in Nursing Discipline
8
Table 1. Definitions of Stigma concept, and Stigma Types Used in Nursing Discipline
Author
Oliveira, Carvalho, & Esteves, 2016
Zelaya, Sivaram, Johnson,
Srikrishnan, Suniti, & Celentano,
2012
Kato, Takada, & Hashimoto, 2014
Type of Stigma
Internalized stigma (self-stigma).
Stigma

Self-stigma: (internalized
stigma)
Definition of Stigma
The process in which a person internalizes stigmatizing beliefs about
mental illness, accepting and applying the negative stereotypes to oneself
Is a social process, discrediting and devaluing individuals or groups with an
attribute that is either feared or sanctioned by society as immoral or deviant
A stigma that is experienced by individuals who have negative Attitudes
towards themselves as a result of their condition And/or characteristics
Represents negative reactions of the general public towards a group Based
on stereotypical attributes that distinguish that group in society

Florom-Smith & Santis, 2012
Public stigma (social stigma)
Stigma


AIDS related
Stigma (Public Stigma)

Felt stigma (Internalized
stigma, self-stigma)

Enacted stigma
- Erving Goffman (1963): an attribute or characteristic that is profoundly
discrediting to the individual possessing the attribute or characteristic.
- Herek (2002): a lasting, negatively valued circumstance, status, or
characteristic that discredits and disadvantages individuals.
Stigma directed at people living with HIV/AIDS (PLWHA) and/or
associated with PLWHA.
A fear of disclosure of HIV serostatus, in anticipation of resultant
discrimination
Discrimination in the forms of rejection, verbal insults, and ostracism
perpetrated by family members and friends, and was manifested as
avoidance related to fears of infection, judgment, and an inability to
understand why spouses or caregivers would choose to remain with people
living with HIV.
Stigma caused by an association with an individual living with a
stigmatizing condition) was experienced by participants’ family and
children via avoidance by friends and family members because of
unfounded fears of infection.
Stigma a Concept in Nursing Discipline
9

Omori, Mori, & White, Self-Stigma
in Schizophrenia: A Concept
Analysis, 2014
Courtesy stigma (Stigma by
association)
Stigma
Self-stigma
Link and Phelan (2001): the term
“Stigma” should be applied “when elements of labeling, stereotyping,
separation, status loss, and discrimination co-occur in a power situation that
allows the components of stigma to unfold” (p. 367).
Stereotyping, prejudice, and discrimination toward oneself
Stigma a Concept in Nursing Discipline
10
Methods
The evaluation of the maturity level of stigma as a concept in nursing discipline was
guided by the four principles recommended by Morse et al. (1996); epistemological, logical,
pragmatical, and linguistical. Stigma related literatures were retrieved by searching the
Cumulative Index to Nursing and Allied Health Literature (CINAHL) via Ebesco and MEDLINE
via PubMed, in addition to Google Scholar. Search terms used were: stigma, stigma concept,
health-related stigma, concept analysis, and nursing. Initial search was restricted to include
published literatures from 2006 to 2016 with full text and presented in English. Some literature
before 2006 were also considered since it included seminal studies and definitions.
Findings
Epistemological
It is the first premise in the principle-based concept analysis method in which concept
should to be clearly identified and well distinct from other concepts in order to be evaluated as a
mature concept (Penrod & Hupcey, 2005).
Previous studies in psychology and the social sciences have extended to Goffman’s
theory to reveal on the nature, sources and consequences of stigma in order to investigate the
wide variation in defining and conceptualizing the concept of stigma (Omori, Mori, & White,
2014; Brinkley-Rubinstein, 2015; Butt, 2008; Engebretson, 2013). Stigma as a concept remains
uncertain, due to the diverse stereotypes and interactive characteristics that belong to the
different health conditions among minorities (Omori, Mori, & White, 2014). Furthermore,
concept of stigma was often discussed in separation from its multiple forms and intersectional
Stigma a Concept in Nursing Discipline
11
exploration, thus, leading to a substantial burden that there is no consensus in the literature on
what the definition of stigma constitutes (Brinkley-Rubinstein, 2015). It is important to highlight
that the meanings of stigma change across cultures or over time. For instance, epilepsy has been
perceived as demon possession, a neurological disorder, as well it was perceived as spiritual gift
from God in the book “The Spirit Catches You and You Fall Down” which described the
struggels between the Hmong culture and the American culture (Fadiman, 1997). Link and
Phelan (2001) Reported that stigma is constantly changing trajectory of human being behavior,
thus, definitions of stigma vary with the context in which it is studied in.
Goffman (1963) in which described stigma as a process in which self identity is flawed by
the social reaction of others. Since, there is an agreement that stigma is a complex and socially
constructed phenomenon experienced by individuals with various diseases in varying contexts;
this necessitates further investigations toward a distinctive definitions for this concept (Weiss,
Ramakrishna, & Somma, 2006). Several contextual variables and health conditions might induce
similar and dissimilar attributes of stigma (Omori, Mori, & White, 2014). Literature showed
different experiences and perceptions of stigma among different individuals with different health
conditions (Butt, 2008; Brinkley-Rubinstein, 2015; Omori, Mori, & White, 2014).
Distinction of stigma concept from its various stances like its definition and reasons of
episode in the lives of people is a matter of challenge (Link & Phelan, 2001). Hence, stigmatized
individuals have been recognized to have several negative attributes, and subsequently they are
treated differently by members of society (Link & Phelan, 2001), it is crucial to review the
uncertainty in conceptualizing the concept of stigma and its impact on the individuals’
conditions. Extending the concept of stigma will help those offering healthcare practices to
provide better care for stigmatized individuals (Link & Phelan, 2006). Therefore, a
Stigma a Concept in Nursing Discipline
12
comprehensive understanding for the complexities linked with the sociocultural, conditional and
structural attributes that influence the experience of stigma should be taken into account for
better differentiation of the concept of stigma (Butt, 2008).
Despite the labeling of a chronic illness as a disease, cultural and social meanings are still
attached to certain diseases to include negative meanings (Engebretson, 2013). Stigma can be
experienced by individuals in many chronic health conditions; such as psychiatric illnesses and
certain sexually transmitted diseases like HIV, however, the response of society to such diseases
and conditions may lead to stigmatization (Engebretson, 2013; Parkera & Aggleton, 2003).
Investigating the universality of stigma and examination of the social perceptions associated with
this process can unify its meaning and promote health behaviors among vulnerable persons
regardless variety of their conditions (Engebretson, 2013). While
Moreover, concepts that are related to stigma have been studied for clarification and
specification. For instance, the concept of “self-stigma” has been examined and was
distinguished from public stigma, particularly among individuals with psychiatric illnesses
(Omori, Mori, & White, 2014). Stereotyping, prejudice, and discrimination are considered as the
basic facets for concept of stigma as well as self stigma (Link & Phelan, 2001), whereas, selfstigma characterized by harmfulness to self-identity (Pinto-Foltz & & Logsdon, 2008) selfstigma can be resulted fron internalized Sociatal stigma (Vogel, Wade, & Hackler, 2007). Many
psychological studies examined perceived self-stigma, perceived public-stigma, and social
distance as common types of stigma (Vogel, Wade, & Hackler, 2007; Evans-Lacko, Brohan,
Mojtabai, & Thornicroft, 2012; Link, 1987 ; Rayan & Jaradat, 2016). Perceived public-stigma is
the extent to which individuals expect that other persons will devalue or discriminate against
Stigma a Concept in Nursing Discipline
13
persons who are mentally ill, while social distance scrutinizes individuals’ willingness to
communicate with persons who are mentally ill ( Vogel, Wade, & Hackler, 2007; Link, 1987).
Stigma can be both externally imposed and internally perceived in a process of self-stigma
(Engebretson J. , 2013).
Logical
It is the second premise in the principle-based concept analysis method refers to the
integration of the concept with related concepts. It also determines whether the conceptual
boundaries are kept through logical and theoretical integration with other concepts (Penrod &
Hupcey, 2005).
Stigma is a broad and complex social phenomenon; therefore several dimensions of stigma
were discussed by psychologists to include perspectives of: visibility, course and perceived
danger, controllability, and perceived stigma (Green, 2009). In addition, three types of stigma
were recognized by Goffman to include: physical defect; personality blemish; and prejudice
(Goffman, 1963). These aspects need rigorous investigation to permit proper and logical
integration of stigma with other concepts.
Social psychologists conceptualized stigma as the co-incidence of: labeling, stereotyping,
separation, and emotional reactions, those often lead to status loss and discrimination (Link &
Phelan, 2001). In the Oxford Dictionary of Sociology, the definition of discrimination is linked
not to stigma but to prejudice and sexism (Marshall, 1998). Prejudice, in turn, is described as
‘‘an unfavorable attitude towards a group or its individual members’’ (p. 522). In contrast,
Sociologist perceived discrimination in the early era as an expression of ethnocentrism, it is
cultural phenomenon of ‘‘dislike of the unlike’’ (Marshall, 1998). Recently, sociologists’
analyses of discrimination perceived it as a pattern of dominance and oppression, and a struggle
Stigma a Concept in Nursing Discipline
14
for power and opportunity” (Marshall, 1998). Persons who are stigmatized are seen as unsafe and
scare others, they are unwanted in the social hierarchy and they are discriminated at their
institutions (Link & Phelan, 2001). Stigma is linked to the expression of social inequality issues
of stigmatization and discrimination in the case of HIV and AIDS related stigma (Parkera &
Aggleton, 2003).
Psychologists concluded that the concept stigma has conceptual adequacy and relevancy
for multiple conditions and circumstances of stigmatized groups (Link & Phelan, 2001; Parkera
& Aggleton, 2003). It was noted that labeling can be classified from attitude, appearance, and
even from medical diseases (Green, 2009). Since stereotyping is one of the basic elements of
stigma it includes a connection to classify labeled individuals (Link & Phelan, 2001). The
concept of stigma succeed to ‘embraces its boundaries’ when it is correlated with other related
concepts in some occasions (Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012; Parkera &
Aggleton, 2003; Vogel, Wade, & Hackler, 2007). The stigmatizing and the stigmatized persons
both are interchangeably used terms to describe the interactive aspects of stigma (Pinto-Foltz &
& Logsdon, 2008). Stigmatizing attitude is shaped by public responses to discredited people,
while stigmatized person was defined as someone expected to be rejected in social activities and
devalued as less trustworthy, intelligent, and competent by socially intact persons (Anglin, Link,
& Phelan, 2006).
Theoretical definition of stigma incorporated logical integration and connectedness with
other related terms like self- stigma, public stigma; internalize stigma, and explicit stigma
(Vogel, Wade, & Hackler, 2007; Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012; Link,
1987; Pinto-Foltz & & Logsdon, 2008; Goffman, 1963).
Stigma a Concept in Nursing Discipline
15
Pragmatical
The third premise in the principle-based concept analysis method is the applicability and
usefulness of the concept and it also determines how it is operationalized (Penrod & Hupcey,
2005). Clearly defined any concept with clinical usefulness is never fully completed because the
concept is dynamic and change over time. Concepts are influenced by history, clinical care and
treatment, and the occurrence of innovative health conditions and diseases (Florom-Smith &
Santis, 2012).
Stigma has enormous definitions and applications, which have inconstancies agreed on it
and often remains unrecognized by nurses within themselves and others; unrecognized stigma is
an obstacle to understand patient behavior (Pinto-Foltz & Logsdon, 2008). Stigma concept was
measured based on variety of populations and mainly measured using self-report indicators and
self-measurement which were specific for particular populations or groups. However, the term
stigma is used to describe both concepts—stigma and self-stigma—it was found that the
definition of stigma is varied in literature (Omori, Mori, & White, 2014).
There are many operational definitions for stigma in nursing literature and many
instruments and questionnaires have been developed to measure specific stigma, thus definitions
of specific stigma related to disease varies from study to study (Florom-Smith & Santis, 2012).
Examples of well-established and most widely used instruments in nursing research include
Ritsher, Otilingam, and Grajales (2003) who developed “Internalized Stigma in Mental Illness
(ISMI)” instrument. This is a 29-item tool rated on a four points Likert scale (1 strongly disagree
to 4 strongly agree). The internalized stigma was defined as " inner subjective experience and its
psychological effects, including alienation, stereotype endorsement, perceived discrimination,
social withdrawal, and stigma resistance'' p32.
Stigma a Concept in Nursing Discipline
16
Another commonly used measure is The Self-Stigma of Mental Illness Scale (SSMIS)
which was developed by Corrigan et al., (2006). This scale has four subscales
(stereotypeawareness, stereotype agreement, stereotype self-concurrence, and self-esteem
decrement) with 40 items; each item is rated on a nine-point agreement scale. The Japanese
version of the Self-Stigma Scale (SSS-J) is another example that contains 39 items allows
responses in 4-point anchored Likert scale: strongly disagree, disagree, agree, and strongly agree.
The responses are afforded a score of 0, 1, 2, and 3, respectively. The complete scores have a
range of 0 to 117; a higher score signifies a higher level of self-stigma (Kato, Takada, &
Hashimoto, 2014).
The concept of HIV-related stigma is well-documented in the research literature; however,
there are gaps related to the utility of this concept. In addition, the definitions and specific
components that focuses on of stigma different from study to study (Nyblade, 2006). Each
different instrument measures components of HIV-related stigma, but none of the current
instruments measure all components of this concept. Consequently none of the instruments is
valuable in measuring this concept across all populations. Therefore, lack of clinical utility of the
concept of HIV-related stigma is obvious (Oliveira, Carvalho, & Esteves, 2016). The concept of
HIV related stigma is not clearly defined, not consistently measured, and remains too abstract for
clinical use.
The concept of stigma cannot be useful clinically because of its abstract nature (FloromSmith & Santis, 2012). More theoretical and empirical works are needed for clarifying the
concept, which will improve the operational definition of the concept.
Examples of applications and instruments used in nursing research are presented in Table 2.
Stigma a Concept in Nursing Discipline
17
Table 2. Application of Stigma Concept in Nursing Researches
Author
And year
Title
Purpose
Target
population
Conceptual
definition
of stigma
Operational
definition of
stigma
Term used to
reflect
stigma
Stigma dimensions
measured
Rayan & Jaradat,
2016
Stigma of
Mental Illness
and Attitudes
Toward
Psychological
Help-seeking in
Jordanian
University
Students
To examine the
level of stigma
toward mental
illness and its
association with
attitudes toward
psychological
help-seeking in
Jordanian
university
students.
519
undergraduate
university
students
Not explicit
The 6-item Social
Distance (SD)
Scale,
The Percieved
DevaluationDiscrimination
(DD) Scale, and
the Attitudes
Toward Seeking
Professional
Psychological Help
Scale (ATSPPHS
Perceived
public stigma
and social
distance
Perceived public stigma
toward mental illness,
Attitudes toward mental
illness, and attitude toward
psychological help-seeking.
Oliveira, Carvalho,
&Esteves,
2016
Internalized
stigma and
quality of life
domains among
people with
mental illness:
the mediating
role of selfesteem
To propose a
theoretical model
in which selfesteem mediates
the effects of
internalized
stigma on the
multidimensional
domains
comprising
quality of life
Psychiatrist
participants
inpatients and
outpatients
Theoretical
model in
which selfesteem
mediated
the
relationship
between
internalized
stigma and
Quality of
life
domains.
Internalized Stigma
of Mental Illness
scale (ISMI). The
Rosenberg SelfEsteem scale
(RSES). World
Health
Organization
Quality of Life
Bref–WHOQOL
Internalized
Stigma
Internalized
Stigma on the
multidimensional domains
comprising quality of life
Kato, Takada, &
Hashimoto, 2014
Reliability and
validity of the
Japanese
version of
the Self-Stigma
Assessed the
psychometric
properties of a
Japanese version
of the Self-
People with
type 2
diabetes
Not
explicitly
mentioned
SSS-J scale.
The Rosenberg
Self-Esteem Scale.
The General SelfEfficacy Scale.
Self-stigma
public stigma
Negative reactions
stereotypical attributes that
distinguish that group
in society
Stigma a Concept in Nursing Discipline
18
Scale in patients
with type 2
diabetes
Stigma Scale
(SSS-J) in
patients with
type 2 diabetes.
The nine-item
depression module
of the Patient
Health
Questionnaire
(PHQ-9)
McGonagle &
Barnes-Farrell,
2014
Chronic Illness
in the
Workplace:
Stigma, Identity
Threat
and Strain
To examine
work-related
chronic illness
stigma, identity
threat and strain
from
the perspective
of the individual
worker through
an
application and
empirical test of
an established
theoretical
model
350 workers
with various
chronic
illnesses
Theoreticall
y based
model of
stigmarelated
identity
threat and
strain using
survey
responses
Non-illness-related
survey items. fivepoint response
scale was used for
all
survey items,
ranging from (1)
Strongly disagree
to
(5) Strongly agree.
A situational
factor.
a personal
characteristic
and metaperceptions
of
devaluation
each related
to identity
threat
perceptions,
which in
turn related to
both strain
and work
ability
Boundary flexibility,
job self-efficacy, and metaperceptions of devaluation
strain and work ability
Molina, Choi,
Cella, & Rao, 2013
The Stigma
Scale for
Chronic
Illnesses 8-Item
Version
(SSCI-8):
Development,
Validation and
Use Across
Neurological
Conditions
To collect data
on the
psychometric
properties of new
instrument,
examine its
factor structure
and study the
severity of
stigma across
condition
Participants
were among
the 581
respondents
from eight
academic
medical
centers who
comprised the
second wave
of a study on
the quality of
life for people
with
neurological
item
response
theory
methodologi
es
Stigma
Scale for Chronic
Illness 8-item
version
Psychological
distress and
patient
performance.
Enacted Stigma and Its
Consequences in
Neurological
Populations.
Internalised Stigma and Its
Consequences in
Neurological
Populations
Stigma a Concept in Nursing Discipline
19
disorders
(Neuro-QOL).
Dalky , 2012a
Arabic
translation and
cultural
adaptation of
the
stigmadevaluation
scale in Jordan
To translate and
culturally modify
the stigmadevaluation scale
(SDS) into
Arabic, and to
test the
reliability,
content and
construct validity
of the Arabic
version of the
SDS
164 family
Caregivers in
Jordan.
The study
adopted the
process of
translation
and crosscultural
adaptation
of an
instrument
as proposed
by Brislin
(1970),
Flaherty et
al. (1988)
and
LopezMcKee
(2005).
Consumers' scale
and consumer
families scale.
Isolation, low
selfesteem
and
discriminatio
n and the
difficulties
associated
with
caregiving
and holding
down a job or
getting
married
Status reduction, role
restriction and community
rejection
Stigma a Concept in Nursing Discipline
20
Linguistical
The fourth premise in the principle-based concept analysis method refers evaluate if it is
the appropriately and consistently used in the context (Penrod & Hupcey, 2005). Stigma is a
complex, multi-faceted construct (Webb, et al., 2016). Without knowing which concept is related
to stigma, it is difficult at this point to know how these other concepts effect or impact stigma
(Nyblade, 2006). Stigma is a social construct that identifies a person by virtue of a physical or
social trait, resulting in negative social reactions such as avoidance and discrimination (Hassan &
Wahsheh, 2011).
Stigma is a universal and multidimensional concept that is experienced in all cultures and
in various stages of life (Pinto-Foltz & Logsdon, 2008). But stigma is a variable from context to
context and it is viewed as negative points which have different dimensions: interpersonal;
intrapersonal; and structural (Butt, 2008).
Despite stigma’s relevance to nursing, few have revealed on the meaning of stigma in
nursing and in patient care, nurses usually seek for the help of psychiatrist and psychologist in
defining stigma (Pinto-Foltz & Logsdon, 2008). Furthermore, while the role of culture on stigma
in the literature is clear, few studies discussed stigma from cultural perspectives (Dalky, 2012b).
Stigma concept should be continuously refined in the context in which it is used.
Discussion
Stigma is a complex phenomenon which can be found in many health care environments
and affects the caring process toward both the individuals and the community. Although there is
a large body of literature that addresses the concept of stigma, there is no consistency in the
definitions, dimensions and operationalizations of stigma.
Stigma concept was evaluated based on Morse et al.’s (1996) principles to assess its level
of maturity. Studies showed that stigma plays a greater role among underserved populations than
Stigma a Concept in Nursing Discipline
21
general populations. Most of studies were consistent in which stigma is a complex and has multi
dimensions. Effective nursing care requires additional ability, awareness, and understanding of
stigma concept among nurses to improve health care process.
While a wide range of studies exist dealing with stigma types, definition, and
measurement, several gaps remain particularly with measuring stigma and defining it (Omori,
Mori, & White, 2014; Florom-Smith & Santis, 2012). Therefore, further concept development
and clarification are needed. Nurses and other health care professionals should work on the
definition of stigma concept and reach global consistency regarding the conceptualization and
operationalization of stigma to keep it related to cultural context (Dalky, 2012b). Nurses should
reach consensus regarding the definition of stigma in order to be appropriately operationalize and
measure it.
Conclusion
Stigma has become an important topic for public health; it contributes to suffering, which
leads to health deterioration, and it interferes with appropriate use of health services. How stigma
is defined can help the nurse to improve the assessment of the patient’s health and to identify
health problems and patient’s needs.
This paper highlights the stigma as a concept related to chronic illnesses, with reference to
prior work in the field; stigma is defined inconsistently in nursing and other disciplines.
Additional concept development and clarification is needed. Stigma with its different types and
dimensions should be defined in a consistent manner in order to improve health care services and
to help nurses and other healthcare professionals provide optimum care process.
Stigma a Concept in Nursing Discipline
22
References
Anglin, D., Link, B., & Phelan, J. (2006). Stigmatizing Attitudes Toward People With Mental
Illness. Psychiatric Services , 57 (6).
Bos, A., Pryor, J., Reeder, G., & Stutterheim, S. (2013). Stigma: Advances in Theory and
Research. Basic and Applied Social Psychology, 34, 1–9.
doi:10.1080/01973533.2012.746147.
Brewis, A. A., & Wutich, A. (2015). A world of suffering? Biocultural approaches to fat stigma
in the global context of the obesity epidemic. Annals of Anthropological Practice, 38 (2),
269–283.
Brinkley-Rubinstein, L. (2015). Understanding the Effects of Multiple Stigmas among Formerly
Incarcerated HIV- Positive African American men. AIDS Education and Prevention , 27
((2)), 167–179.
Brunton, K. (1997). Stigma. Journal of Advanced Nursing, 26, 891–898.
Butt, G. (2008). Stigma in the context of hepatitis C: concept analysis. Journal of Advanced
Nursing, 62(6), 712-724. doi:10.1111/j.1365-2648.2008.04641.x.
Copel, L & Al-Mamari,K. (2015). Stigma in Mental Health: A Concept Analysis College of
Nursing, Villanova University, Villanova, PA. Sigma Theta Tau Internationa.l
Corrigan, W. P., Watson, C. A., & Barr, L. (2006). The selfstigma of mental illness: Implications
for self-esteem and self-efficacy. Journal of Social and Clinical Psychology, 25(9), 875–
884.
Dalky, H.F. (2012a ). Arabic translation and cultural adaptation of the stigma-devaluation scale
in Jordan. Journal of Mental Health, 21(1): 72–82.
Stigma a Concept in Nursing Discipline
23
Dalky, H. F. (2012 b). Perception and coping with stigma of mental illness: Arab families'
perspectives. Issues Ment Health Nurs.33(7):486-91. doi:
10.3109/01612840.2012.676720.
Engebretson, J. (2013). Understanding stigma in chronic health conditions: Implications for
nursing. Journal of the American Association of Nurse Practitioners , 25, 545–550.
Evans-Lacko, S., Brohan, E., Mojtabai, R., & Thornicroft, G. (2012). Association between public
views of mental illness and self-stigma among individuals with mental illness in 14
European countries. Psychological Medicine , 42 (8), 1741-1752.
Fadiman, A. (1997). When the spirit catches you and you fall down. New York, NY.
Florom-Smith, A., & Santis, J. (2012). Exploring the Concept of HIV-related Stigma. Nursing
Forum, 47(3), 153-165.
Goffman, E. (1963). Stigma.Notes on the Management of Spoiled Identity. New York: Simon
and Shuster.
Green, G. (2009). The end of stigma? Changes in the social experience of long-term illnes. New
York, NY: Routledge.
Hassan, Z.M & Wahsheh, M. A. (2011). Knowledge and Attitudes of Jordanian Nurses towards
Patients with HIV/AIDS: Findings from a Nationwide Survey . Issues in Mental Health
Nursing, 32:774–784.
Herek, G. M. (2002). Thinking about AIDS and stigma: a psychologist’sperspective. Journal of
Law, Medicine & Ethics , 30 (4), 594–607.
Kato, A., Takada, M., & Hashimoto, H. (2014). Reliability and validity of the Japanese version
Stigma a Concept in Nursing Discipline
24
of the Self-Stigma Scale in Patients with Type 2 Diabetes. Jiurnal of Health and Quality of
Life Outcomes, 12(179), 1-9. doi:10.1186/s12955-014-0179-z.
Lim, K. S., & Tan, C. T. (2014). Epilepsy stigma in Asia: The meaning and impact of stigma.
Neurology Asia, 19(1), 1-10.
Link, B. G., & Phelan, J. C. (2006). Stigma and its public health implications. Lancet , 367, 528–
529.
Link, G. B., & Phelan, C. J. (2001).Conceptualizing stigma.Annual Review of Sociology, 27,
363–385.
Link, B G. (1987). Understanding labeling effects in the area of mental disorders: An assessment
of the effects of expectations of rejections. American Sociological Review , 52, 96-112.
Marshall, G. (1998). Oxford dictionary of sociology . Oxford and New York: Oxford University
Press.
McGonagle, A.K & Barnes-Farrell, J. L.(2014). Chronic Illness in the Workplace: Stigma,
Identity Threat and Strain. Stress Health , 30: 310–321.
Molina, Y., Choi, S.W., Cella, D., & Rao, D.( 2013). The Stigma Scale for Chronic Illnesses 8Item Version (SSCI-8): Development, Validation and Use Across Neurological
Conditions. Int.J. Behav. Med, 20:450–460.
Morse, J. M., Hupcey, J. E., Mitcham, C., & Lenz, E. R. (1996). Concept analysis
in nursing research: A critical appraisal. Research and Theory for Nursing
Practice, 10(3), 253–277.
Nyblade, L.C. (2006). Measuring HIV stigma: existing knowledge and gaps. Psychology, Health
& Medicine, 11:335–345.
Stigma a Concept in Nursing Discipline
25
Oliveira, S., Carvalho, H., & Esteves, F. (2016). Internalized stigma and quality of life domains
among people with mental illness: the mediating role of self esteem. 25(1), 55–61.
doi:10.3109/09638237.2015.1124387.
Omori, Y., Mori, C., & White, A. (2014). Self-Stigma in Schizophrenia: A Concept Analysis.
Nursing Forum, 259-266.
Oxford Advanced Learner's Dictionary. (2016).Definition of stigma.Retreived in 11 March 2016
from http://www.oxfordlearnersdictionaries.com/definition/english/stigma.
Parcesepe AM, Cabassa LJ .(2012). Public stigma of mental illness in the United
States: A systematic literature review. Adm Policy Ment Health. Available:
http://link.springer.com/article/10.1007？%2Fs10488-012-0430-z .
Parkera, R., & Aggleton, P. (2003). HIV and AIDS-related stigma and discrimination: a
conceptual framework and implications for action. Social Science & Medicine , 57 , 13–
24.
Penrod, J., & Hupcey, J. E. (2005).Enhancing methodological clarity: Principle-based concept
analysis. Journal of Advanced Nursing, 50(4), 403–409.
Pinto-Foltz, M., & Logsdon, C. (2008). Stigma Towards Mental Illness: A Concept Analysis
Using Postpartum Depression as an Examplar. Issues in Mental Health Nursing, 29, 21–
36. doi:10.1080/01612840701748698.
Rayan, A., & Jaradat, A. (2016). Stigma of Mental Illness and Attitudes Toward Psychological
Help-seeking in Jordanian University Students. Research in Psychology and Behavioral
Sciences , 4 (1), 7-14.
Stigma a Concept in Nursing Discipline
26
Ritsher, J. B., Otilingam, P. G., & Grajales, M. (2003).Internalized stigma of mental illness:
Psychometric properties of a new measure. Psychiatry Research, 121(1), 31–49.
Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived Public Stigma and the
Willingness to Seek Counseling: The Mediating Roles of Self-Stigma and Attitudes
Toward Counseling. Journal of Counseling Psychology , 54 (1), 40–50.
Waltz, C. F., Strickland, O., & Lenz, E. R. (2010). Measurement in nursing and
health research (4th ed.). New York: Springer.
Webb, M., Jessica, P., Stephanie, C.W., Heather, R., Erin, S., & Jess, C. (2016). The role of
empathy and adult attachment in predicting stigma toward severe and persistent mental
illness and other psychosocial or health conditions. Journal of Mental Health
Counseling, 38(1).
Weiss,M., Ramakrishna, J & Somma, D. (2006). Health-related stigma: Rethinking
concepts and interventions. Psychology, Health & Medicine; 11(3): 277 – 287.
Zelaya, C., Sivaram, S., Johnson, S., Srikrishnan, A., Suniti, S., & Celentano, D. (2012).
Measurement of self, experienced, and perceived HIV/AIDS stigma using parallel scales
in Chennai, India. Journal of AIDS Care, 24(7), 846-855. doi:10.1080/0954.