Action Framework for Building an Inclusive Health System

The Chief Public Health Officer's Report on the State of Public Health in Canada 2019

The table includes examples of stigma practices, interventions and potential outcomes taken from relevant literature. These examples are not exhaustive.

An evidence summary on interventions to address stigma in the health system will be available on the 2019 CPHO annual report web page.

How stigma operates Interventions to address stigma Potential outcomes
Individual level of stigma: person who experiences stigma
  • Enacted stigma (i.e., unfair treatment) (e.g., psychological stress)
  • Internalized stigma (e.g., low self-esteem and feelings of shame)
  • Anticipated stigma (e.g., does not access support)
  • Group-based supports to change stigmatizing beliefs, improve coping skills, support empowerment, and build social support
  • Reduction in internalized stigma
  • Improved psychological well-being and mental health
Interpersonal (person-to-person) level of stigma: family, friends, social and work networks, healthcare and service providers
  • Language (e.g., using derogatory terms or dehumanizing labels; refusing to use preferred name and/or pronoun)
  • Intrusive attention and questions
  • Hate crimes and assault
  • Education interventions to target myths and lack of knowledge. Include components that encourage examining personal values, biases, and beliefs
  • Contact interventions, including sharing personal stories, to target stigmatizing beliefs and attitudes
  • Better understanding of the facts about stigmatized health conditions
  • Increased understanding of diverse perspectives and experiences of stigma
  • Growing social acceptance
  • Reduction in stereotyping
Institutional level of stigma: health system organizations, medical and health training schools, community sector organizations, social service organizations
  • Being made to feel "less than" (e.g., having to wait longer than others to be seen; lack of empathy from staff)
  • Physical environment is not inclusive (e.g., washrooms are single-sex; undersized chairs in public areas)
  • Institutional policies that cause harm (e.g., unnecessary drug tests; low investment of services)
  • Ongoing and continued training targeting conscious and implicit bias
  • Implementation of cultural safety and cultural humility models
  • Safe and inclusive physical environments
  • Workforce diversity initiatives
  • Institutional collaboration with community; policies that support and fund meaningful engagement with people with lived experience of stigma
  • Implement trauma- and violence-informed care models
  • Accountability and monitoring frameworks that include stigma reduction indicators
  • Institutional environment is inclusive, welcoming and diverse
  • Organizations are able to meet the needs of all populations
  • Reduction in stigmatizing beliefs and attitudes among staff
  • Improved patient/client ratings of care, satisfaction and trust
  • Patient/client outcomes improve
Population level of stigma: mass media, policies, and law
  • Widely held stereotypes
  • Negative portrayals in film and television (e.g., people with mental illness portrayed as violent)
  • Discriminatory policies and laws
  • Inadequate legal protections, or lack of enforcement of these protections
  • Mass media campaigns to challenge stereotypes and prejudice
  • Guidelines to reduce stigma in media reports
  • Protective laws and policies
  • Addressing discrimination within existing laws and policies
  • Reduction in stigmatizing beliefs, attitudes, and intended behaviour among the public
  • Reduction in discrimination practices

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