Fuzzy Boundaries in HIV Stigma

blear Boundaries in human immunodeficiency virus defacementFuzzy Boundaries in theConceptualization of human immunodeficiency virus disfigurement Moving Towards a MoreUnified ConstructCurrently, in that respect are 36.7 million large number invigoration with human immunodeficiency virus (PLWH) worldwide (WHO, 2017). human immunodeficiency virus-related print inhabits to be a major concern for PLWH in the United States and a topic (Baugher et al., 2017 Bogart et al., 2008 Herek, Capitanio, & Widaman, 2002 X. Li, Wang, Williams, & He, 2009 Odindo & Mwanthi, 2008) with more(prenominal) than 50% of men and women reporting discriminatory attitudes toward PLWH among countries with data operable (UN back up, 2015). This is particularly disconcerting given that human immunodeficiency virus-related tarnish has shown to be associated with injurious popcomes in the physical and genial wellness of PLWH, higher levels of human immunodeficiency virus patsy being match with higher depression symptoms (L. Li, Lee, Thammawijaya, Jiraphongsa, & R early(a)am-Borus, 2009 Onyebuchi-Iwudibia & Brown, 2014 Rao et al., 2012), get down adherence to antiretroviral therapy (Katz et al., 2013), and less entre and usage of complaisant and health handle services (Chambers et al., 2015 Rueda et al., 2016). In general, human immunodeficiency virus-related marking has cogitate on the individualist assure of crisscross by PLWH and has been conceptualized into three dissimilar types (Earnshaw & Chauinsider, 2009 Nyblade, 2006) the fear of contradict attitudes, judgment, and discrimination from human immunodeficiency virus position and serostatus disclosure ( comprehend firebrand), the credenza of negative stereotypes associated with human immunodeficiency virus as part of the self or individualism operator ( inheringized grunge), and the actual experience of discrimination by PLWH (enacted patsy).More recently, some conceptualizations take in highlighted the i mportance of considering human immunodeficiency virus-related scar beyond the individual context as grunge is a social sue, a pattern of thoughts, feelings, and behaviors that lick change and knead in ball club (Deacon, 2006 tie beam & Phelan, 2001 Mahajan et al., 2008 poseer & Aggleton, 2003). This recent shift has led queryers to propose several revisions to the human immunodeficiency virus deformity construct. In particular, they argue that human immunodeficiency virus-related sign should be distinguished from discrimination (Deacon, 2006) and that it should be broadsheetd at morphologic and institutional levels (Link & Phelan, 2001 Mahajan et al., 2008 Parker & Aggleton, 2003). Since the conceptualization of human immunodeficiency virus-related print has practical implications on how it is studied, measured, and treated, the purpose of this paper is to review article the validity of the proposed revisions. It will be argued that despite at that place being a st rong metaphysical basis for some(prenominal) changes to the conceptualization of human immunodeficiency virus-related stigma, psychometric seek suggests that enacted stigma should not be removed from the construct, but that HIV-related stigma should be measured crosswise socio-ecological levels.Theoretical Implications of HIV gull as a friendly ProcessA majority of the stigmaliterature derives from the hit of sociologist, Erving Goffman. His originaltheory viewed stigma as a social process (Goffman,1963), which has measurableimplications on the conceptualization of HIV-related stigma, as look for inthis ambit has primarily foc employ on the construct at an individual level. flaw as a Social Process The conceptualization ofHIV-related stigma much departs from the definition proposed by Goffman. Goffmandefined stigma as an property that is deeply discrediting according tosociety, which diminishes the stigmatized individual from a whole and usual mortal to a tainted, discou nted unrivaled (Goffman, 1963). Although Goffman acknowledgedthe role of society in stigmatization, researchers limit their definition ofHIV stigma and cite sections from Goffman that emphasize stigma as an interior(a)or individual level construct (Link & Phelan, 2001 Parker & Aggleton,2003). Notably, they highlight how the deviant or undesirable difference ofstigma leads to the assumption of a spoilt identity (Goffman, 1963). This operationalizationis material beca role it implies that the negative value of stigma comes fromthe individual instead of society. entire at heartGoffmans definition was the arrangement that stigma is a sociallyconstructed concept. He qualified that even though stigma would refer to anattribute it actually was a language of relationships that was rentd(Goffman, 1963). In other words, Goffman argued that society determines what isdiscrediting and thereby develops a structure that delineates how the bearersof stigma are devalued cross directions their social relationships. Subsequently, similarto development in Bronfenbrennersecosystem theory (1997), stigma could be seen more as a dynamic social processthat is constantly changing over time (Parker & Aggleton, 2003). HIV mug and disagreementWhen HIV stigma isconsidered as a social process, the fuzzy limit surrounded by HIV stigma anddiscrimination becomes clearer. Discrimination highlights the perpetrators of stigmatization,whereas stigma refers to the targets of these negative behaviors (Link& Phelan, 2001 Mahajan et al., 2008 Sayce, 1998). This distinction isimportant as it has broader social implications in determining who is liable for stigmatization (Sayce, 1998). By differentiating HIV-related stigmafrom discrimination, it focuses the blame on the social processes entangled withstigmatization rather than on the individual. Deacon (2006) alsoargues how including discrimination within the construct of HIV-related stigmaconstitutes conceptual inflation. Within the stigma literature, discriminationis operationalized as an end result of stigma (Jacoby,1994 Nyblade, 2006) much(prenominal) that the term stigmabecomes synonymic with both the stigmatizing beliefs themselves and theeffects ofstigmatization processes (Deacon,2006). This definition limitsthe understanding about the erratic effects of stigma because it becomes unclearwhether discrimination mediates the association between stigma and various healthoutcomes. In all, there is a practical and theoretical basis fordifferentiating HIV stigma from discrimination. HIV Stigma at the morphological Level Since Goffman,researchers have expounded upon the sociological aspects of his theory toinclude the geomorphologic conditions that influence stigma. Link and Phelan (2001)describe how stigmatization cease only occur when labeling, stereotyping,separation, status loss, and discrimination happens within the context of animbalance in power. In other words, all individuals, including those that arestigm atized, can engage in processes related to the stigmatization. Link andPhelan (2001) discuss an example where an individual with psychogenic infirmity couldstereotype one of their clinicians as a pill-pusher. While the person mighttreat the clinician otherwise on thebasis of this stereotype, without any economic, social, cultural, and politicalpower, the individual cannot enact detrimental consequences against the clinician,and therefore the clinician and his or her identifying group would not bestigmatized (Link& Phelan, 2001). For PLWH, Parker and Aggleton(2003) further desexualise that stigmatization is not only contingent upon thesesocial inequities, but that stigma also serves to strengthen and perpetuatedifferences in morphological power and control. In particular, they argue that stigmaincreases existing power differentials through devaluing groups and heighteningthe feelings of high quality in others. In recognizing that stigma functions at morphologic and institutiona l levels, Park and Aggleton (2003) believe thatstigma is a central component in groundon these theories, it has been proposed that HIV stigma be measured at the structural and institutional level (Mahajan et al., 2008). bill of HIV Stigma knowledge and understanding about HIV stigma is predicated on researchers ability to reliably and accurately measure the construct. In turn, even though there is theory to ache the differentiation of HIV stigma from discrimination and the touchstone of HIV stigma at the structural level, a review of relevant psychometric research is necessary to validate these revisions to the HIV-related stigma construct. HIV Stigma ScaleThe HIV Stigma Scaledeveloped by Berger, Ferrans, and Lashley (2001) is the most commonly usedstigma measure for PLWH (Sayleset al., 2008). It has a total of 40 incidents scored on a Likert descale from 1 (strongly disagree) to 4 (strongly agree)with higher tons indicating higher levels of stigma. The internal consistencyof t he measure has been reliable with different populations, including AfricanAmericans (Rao,Pryor, Gaddist, & Mayer, 2008 Wright, Naar-King, Lam, Templin, & Frey,2007) and PLWH in coarse NewEngland (Bunn,Solomon, Miller, & Forehand, 2007).More recently, the HIV Stigma Scale was adapted for use in South India anddemonstrated high reliability and validity (Jeyaseelanet al., 2013). psychometric Evidence for Measuring HIV Stigma as a Social ProcessConstruct validity forthe HIV Stigma Scale is back up by associations with related measures (Berger,Ferrans, & Lashley, 2001).In terms of measuring HIV stigma as a social process, the total HIV stigmascores and the subscale scores on the HIV Stigma Scale show check up on negativecorrelations with social support availability, social support validation, andsubjective social integrations, as well as moderate positive correlations withsocial conflict. similar relationships were found between HIV stigma and socialsupport in a meta-analysis by Rued a et al., (2016), higher HIV stigma beingassociated with lower social support across studies. Overall, there seems to bepreliminary grounds that HIV stigma should be conceptualized as a socialprocess.psychometric Evidence against Chancing the Current Construct of HIV StigmaThrough wildcat federal agent analysis, Berger et al., (2001) determined that there were fourinterrelated factors from the HIV Stigma Scale personalized stigma, disclosureconcerns, concern with ordinary attitudes toward populate with HIV, and negativeself-image. These factors could be recoded using current conceptualization ofHIV stigma such that personalized stigma is enacted stigma, disclosure concernsand concerns with habitual attitudes toward people with HIV is perceived stigma,and negative self-image is internalized stigma (Earnshaw& Chauinsider, 2009). Further analysis byBerger et al., (2001) led to the declension of one higher-order factor. While this provided further evidence of constructvalidity for the HIV Stigma Scale, if considered within the context of therecoded factors, it would indicate that enacted stigma should not be removedfrom the conceptualization of HIV-related stigma. Psychometric bank billment of HIV-Related Stigma at geomorphological Levels Research on themeasurement of HIV-related stigma at structural and institutional levels issparse and limited (Chan& Reidpath, 2005 Mahajan et al., 2008). Of the studiesavailable, only descriptive information is provided on the experience of structuralstigma for PLWH (Biradavolu,Blankenship, Jena, & Dhungana, 2012 Yang, Zhang, Chan, & Reidpath,2005).Within the larger stigma literature itself, really fewresearchers have considered measuring stigma across different socio-ecologicallevels (Gee,2008 Hatzenbuehler et al., 2014). However, there hasbeen growing evidence to suggest that structural levels of stigma areassociated with individuals levels of stigma (Evans-Lacko,Brohan, Mojtabai, & Thornicroft, 2012 Pachankis et al., 2015).In their study,Evans-Lacko et al., (2012) attempted to examine the relationships betweenstructural and individual levels of mental illness stigma in 14 Europeancountries. To do so, they combine two international datasets (theEurobarometer survey and the Global Alliance of Advocacy Networks study) andcompared public attitudes related to mental illness with individual measures ofinternalized stigma, empowerment, and perceived discrimination among individualsdiagnosed with a mental disorder. Evans-Lacko and his colleagues (2012) foundthat people with mental illness in countries with more positive attitudes(lower structural stigma) reported lower rates of internalized stigma andperceived discrimination than in countries with higher levels of structuralstigma. Even though both datasets were cross-sectional, limiting casualinferences from the study, the results indicate that there are associationsbetween the measurement of structural and individual levels of stigma (Evans-Lackoet a l., 2012 Major, Dovidio, & Link, 2017). In all, there conducts tobe more research to validate the measurement of HIV-related stigma at structuraland institutional levels.LimitationsDue to the want ofexperimental research on enacted and structural HIV stigma (Mahajanet al., 2008 Nyblade, 2006), relevant studies in thisarea may live on from a file drawer problem. In other words, the prevalence ofsignificant results could be inflated given that there are no incentives for create non-significant findings. Moreover, a majority of HIV stigma studiesutilize a correlational design, and so the directionality of these associationscannot be determined. Thus, even though the understanding of HIV stigma hasimproved, the effect size and causality of relationships within the constructrequire further analysis and clarification.Another demarcation isthat there is heterogeneousness in the conceptualization and measurement ofHIV-related stigma, which makes it difficult to compare and contrast res ults (Grossman& Stangl, 2013). Across HIV stigma opinions, researchers measure enacted, perceived, and internalized stigma,suggesting that these are important factors in the conceptualization ofHIV-related stigma (Earnshaw& Chauinsider, 2009). However, many measuresconflate different constructs with HIV-related stigma and include it in asingle scale or subscale (Hereket al., 2002 Kalichman et al., 2009 Visser, Kershaw, Makin, & Forsyth,2008). This indicates thatthere still might be ambiguity in terms of how HIV-related stigma isoperationalized. One final limitation is that the high internal consistency of the HIV Stigma Scale (Berger et al., 2001) could be reflective of an attenuation paradox (Clark & Watson, 1995). For example, the factors of disclosure concern and concern with public attitudes toward people with HIV might be redundant. Both factors represent and can be recoded as aspects of perceived stigma (Earnshaw & Chauinsider, 2009). While the HIV Stigma Scale might be reliab le and internally consistent, the high correlations between the items on the scale might compromise construct validity of ImplicationsA commonconceptualization of HIV stigma is fundamental for future research, mind,and give-and-take (Deacon, 2006 Grossman & Stangl, 2013 Mahajan et al., 2008).Without a unified construct of stigma, progress in the field of HIV-relatedstigma will continue to be impeded by a lose of standardization and incrementalvalidity. The absence of meta-analyses within the literature provides evidenceof the bar in parsing through the heterogeneity of the HIV stigma construct(Grossman & Stangl, 2013). approaching research, then, should prioritizereaching a working consensus on the conceptualization of HIV stigma anddeveloping an agenda that ensures consistent application of thatconceptualization across studies.From this commonconceptualization of HIV-related stigma, current measures such as the HIVStigma Scale should be refined (Bergeret al., 2001). While conv ergentvalidity has been time-tested through correlations with related measures andconstructs (Bergeret al., 2001 Earnshaw & Chauinsider, 2009), more research shouldfocus on the modify the discriminant validity of these measures.Specifically regarding the HIV Stigma Scale, given that several of the items loading onto multiple scales of the measure (Bergeret al., 2001 Rao et al., 2008), future revisionsshould work on improving item discrimination (Sayleset al., 2008). By refining themeasures of HIV stigma in join with the conceptualization of HIV stigma,the operationalization of the different HIV stigma types can be improved. In addition, it is necessary to develop complementary measures to assess HIV-related stigma at structural and institutional levels (Chan & Reidpath, 2005 Deacon, 2006 Mahajan et al., 2008). Research efforts within the field of mental illness and stigma could be leveraged to formulate these assessments (see structural stigma section). While it is important to u nderstand the impact of HIV stigma across a word form of social contexts, it is impractical to begin efforts into this area simply by conducting a large number of studies in different environments. Initial efforts should focus on targeting a smaller range of institutions that have presented unique challenges towards PLWH in the ultimo such as healthcare and then build additional measurements out from there if necessary (Chan & Reidpath, 2005). From a more practical perspective, interventions for HIV-related stigma need to yell the discriminatory behaviors experienced by PLWH. Despite significant heterogeneity in the HIV stigma literature (Grossman & Stangl, 2013), enacted stigma is a factor that is seen across various measurements and operationalizations of the construct (Earnshaw & Chaudoir, 2009). In terms of treatment outcomes, diminution discrimination against PLWH could have important implications as enacted stigma is negatively correlated with indicators of physical health , including CD4 count and chronic illness comorbidity (Earnshaw, Smith, Chaudoir, Amico, & Copenhaver, 2013). Thus, future intervention research should work on addressing enacted stigma as a specific body politic of HIV stigma, measuring enacted stigma consistently across studies, and testing its prophetical validity for treatment, care, and prevention outcomes for PLWH (Grossman & Stangl, 2013). ConclusionBased on the current nomological net, HIV-related stigma should not be differentiated from discrimination. However, there is a need to measure HIV-related stigma in structural and institutional contexts. HIV stigma is a social process that works at the individual level, but the stigmatized person may not be the most important determinant in the development of stigma. Several researchers have theorized that stigmatization is contingent on structural inequities (Link & Phelan, 2001 Mahajan et al., 2008 Parker & Aggleton, 2003) such that interventions that only target stigma and di scrimination may purify the negative physical and mental health outcomes associated with stigma, but not address the entire problem and construct (Chan & Reidpath, 2005).Ultimately, more research is required in order to measure HIV-related stigma across socio-ecological levels (Bronfenbrenner, 1977 Grossman & Stangl, 2013). Given the heterogeneity and lack of standardization within the HIV stigma literature, it is imperative that researchers in this field understand that science and test validity holds social power and influence. Measurement and psychometrics can drive change in social constitution and ideology within society (Messick, 1995). While it is easy to rely on the eminence and eloquence associated with the label of science (Isaacs & Fitzgerald, 1999), researchers have an ethical committal to follow rigorous standards of empiricism because their work can impact the lives of people. This consignment should be true for all people, but especially for groups like PLWH that continue to suffer from stigmatization. ReferencesBaugher, A. R., Beer, L., Fagan, J. L.,Mattson, C. L., Freedman, M., Skarbinski, J., & Shouse, R. L. (2017).Prevalence of Internalized HIV-Related Stigma Among HIV-Infected Adults inCare, United States, 20112013. back up andbehavior, 21(9), 2600-2608. doi10.1007/s10461-017-1712-yBerger, B. E., Ferrans, C. E., &Lashley, F. R. (2001). Measuring stigma in people with HIV psychometricassessment of the HIV stigma scale. ResNurs Health, 24(6), 518-529. Biradavolu, M. R., Blankenship, K. M.,Jena, A., & Dhungana, N. (2012). 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