Unpacking the dynamics of double stigma: how the HIV-TB co-epidemic alters TB stigma and its management among healthcare workers.

BACKGROUND: HIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this co-epidemic remain relatively unexplored. More specifically, no research has quantitatively explored the double stigma associated with HIV and TB in this context, and more specifically the impact of the co-epidemic on [1] the stigmatisation of TB and [2] the TB stigma mangement strategy of covering (i.e. the use of TB as a cover for having HIV). The current study aims to address this research gap by disentangling the complex mechanisms related to HIV-TB stigma. METHODS: Using Structural Equation Modelling (SEM), data of 882 health care workers (HCWs) in the Free State province, South Africa, are analysed to investigate the link between the stigmatization of HIV and TB and the stigma management by those affected. The current study focuses on health care workers (HCWs), as both TB and HIV have a severe impact on this professional group. RESULTS: The results demonstrate that the perceived link between the epidemics is significantly associated with double HIV-TB stigmatization. Furthermore, the link between the illnesses and the double stigma are driving the stigmatization of TB. Finally, the link between HIV and TB as well as the stigmatization of both diseases by colleagues are associated with an increased use of covering as a stigma management strategy. CONCLUSIONS: This is the first quantitative study disentagling the mediating role of double stigma in the context of the co-epidemic as well as the impact of the co-epidemic on the social connotations of TB. The results stress the need for an integrated approach in the fight against HIV and TB recognizing the intertwined nature of the co-epidemic, not only in medical-clinical terms, but also in its social consequences. TRIAL REGISTRATION: South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Layered stigma? Co-occurring depression and obesity in the public eye.

OBJECTIVES: Obesity and depression are common conditions in the general public and show a high level of co-morbidity. Both conditions are stigmatized, i.e., associated with negative attitudes and discrimination. Previous research shows that devalued conditions can overlap or combine to produce a layered stigma which is associated with more negative health outcomes than either single devalued condition alone. This study therefore set out to investigate the double stigma of obesity and depression. METHODS: A telephone-based representative study of the German population was conducted. Vignettes describing women with obesity, depression or both conditions were presented, followed by a set of items on semantic differentials based on previous stigma research of depression (depression stigma DS) and obesity (Fat Phobia Scale FPS). Personal experience with depression and obesity was assessed. RESULTS: All comparisons were significant in univariate ANOVA, showing negative attitudes measured by the FPS and the DS to be most pronounced in the double stigma condition. Multivariate analysis, controlling for age, gender, education and personal experience with the stigma condition (e.g. having obesity or depression), show that the double stigma obesity and depression is associated to more negative attitudes on the FPS (b=0.163, p<0.001) and the DS (b=0.154, p=0.002) compared to the single-stigma condition. CONCLUSIONS: The magnitude of the layered stigma of obesity and depression may need to be considered in mental health settings when treating the depressed patient with obesity, but likewise in obesity care when treating the obese patient with depression.