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A Double Stigma: combined physical - mental illness & inequalities in health care. Chris Platania-Phung Prof Brenda Happell Dr David Scott Institute for Health & Social Science Research Central Queensland University June 2, 2011 Rockhampton. Introduction.
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A Double Stigma: combined physical - mental illness & inequalities in health care Chris Platania-Phung Prof Brenda Happell Dr David Scott Institute for Health & Social Science Research Central Queensland University June 2, 2011 Rockhampton
Introduction People with serious mental illness have much lower physical wellbeing than the general population There are inequalities in physical care for people classified as having serious mental illness Inequalities in access and quality of care may be partly due to mental (illness) stigma and physical (illness) stigma Research directly on multiple stigmas and health care is urgently required
Overview Physical ill-health & mental ill-health Health care inequalities Stigma A Double-Stigma: • Mental • Physical Obesity stigma Research on stigma Research steps on multiple stigmas
The physical health of people with serious mental illness Co-morbidities Longevity Saha et al. (2007, p. 1128):
Reasons for link between mental & physical illness? Socio-Economic conditions (e.g. Wilton, 2004) Medication side-effects Lifestyle Health care systems • Inequality in access and quality of care • Fragmentation in care services & philosophies of care
Inequalities in physical care for people with SMI Duty to Care Report (Lawrence, Holman & Jablensky, 2001) Recent literature reviews (e.g. Scott, Happell, Platania-Phung, in press) Most common reason? • Mental illness stigma • Also physical stigma?
Stigma “A stigma is a culturally recognised attribute that is used to differentiate and discredit a person. The stigma may be physical (a bodily deformity), behavioral (for example, a sexual preference), or social (in the sense of membership of a group). The identification of the stigma is used to reduce the person form a complex whole, to a single, tainted and discounted trait, upon which all social interaction with the person will be based.” (Edgar & Sedgwick, 1999, p. 381)
Stigma is toxic Individual Individual associates (Hebel & Mannix, 2003) Places (Keenem & Padilla, 2010) Groups (McGorry) Societies >> Health, wellbeing
Stigma reduction Contact (Alexander & Link, 2003; Happell) Education (Happell; Sartorius, 2007) Empathy (Teachman et al., 2008) Social consensus perceptions (Puhl, Schwartz & Brownell, 2005)
Health care gap debates Why mental stigma? • Coming from mental health service point of view • Fragmentation in research literature also a problem (not only care models & services) What about physical stigma?
Beliefs/assumptions Belief sets and assumptions (e.g. see Rothblum & Solovay, 2009): • “Fat is bad” • Body weight can be changed through willpower & self- control, behaviour change • ‘Happiness’ and ‘better life’ follows major weight loss • Physical appearance reflects qualities of the inner self (Inner ‘thin’ self underneath) • ‘Just World’ Beliefs
Stigma of obesity: disgust Vartanian 2010, p. 1304
Obesity stigma Everyday events (Puhl & Heuer, 2009) Schools (Puhl & Heuer, 2009) Job selection, pay, employment (Judge & Cable, 2010; Puhl & Brownell, 2001; Swami et al. 2008; Rudolph, 2009) Health care (Teixeira & Budd, 2010; Schwartz et al., 2003)
Obesity & mental illness Obesity & mental illness co-occurrence (Gariepy, Nitka, Schmitz, 2010; Shafer & Ferraro, 2011; Morris et al., 2010) Experienced stigma, distress & mental illness
Challenging anti-fat bias & prejudice A fat-hating society asks fearfully, “Do I look fat?” I respond, “I am fatacus!”….Fat functions as a floating signifier, attached to individuals based on power relationships, not a physical measurement. People all along the weight spectrum may experience fat oppression…I welcome thin people not as allies but as colleagues. Instead, the conflict is between all of us against a system that would weigh our value as people. If we cannot feel at home in our own skins, where else are we supposed to go?” (Wann, 2009)
A turn in Nutritional Sciences? Questioning the ‘weight paradigm’ (Bacon & Aphramor, 2011): • Efficacy of weight reduction programs • ‘Good’ outcomes from large weight loss • Stigma as a motivator Instead: • Health-At-Every-Size-Programs • Clinical efficacy & ethics
Obesity stigma: implications for combined care Obesity stigma (and other ‘physical’ stigmas) are not considered in research/policy on inequalities in physical care for people with SMI
Evidence for stigma: consumer viewpoints Qualitative studies of consumer experiences while in health care (e.g. van den Tillaart et al., 2009)
Evidence for stigma/bias: attitudes Explicit • Self-report (e.g. Schwartz et al., 2006) • Behaviours observed (e.g. Hebl & Mannix, 2003) Implicit • Implicit Association Test (Teachman et al., 2003) • Brain imaging (Schupp & Renner, 2011)
Miller & Lundgren p.714 Experimental paradigm
Experimental paradigm McFerran et al., (2010)
Stigma (physical/mental) & Quality of Care Lower standard of care due to mental illness stigma Lower standard of care due to physical stigma (also interventions, see Wott & Carels, 2010) Need to look at both and as potential sources of inequality in care between general population and people with SMI
Researching double stigma’ Views of consumers with SMI Views/conduct of health care staff Evidence for a double stigma effect Reduction of multiple stigmas
Further progressing the research Duality of ‘mental’ & ‘physical’ Intersectionality Anti-stigmatization may be stigmatizing
People with serious mental illness have much lower physical wellbeing than the general population There are inequalities in physical care for people classified as having serious mental illness Inequalities in access and quality of care may be partly due to mental (illness) stigma and physical (illness) stigma Research directly on multiple stigmas and health care is urgently required
Social relationships Holt-Lunstad, Smith & Layton, 2010 (p. 14)
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