REVIEW ARTICLE
DOI: 10.11606/issn.1806-6976.smad.2018.000367

 

The self-stigma of alcohol and illicit drug users and health services: an integrative review of the literature

 

El auto-estigma de los usuarios de alcohol y drogas ilícitas y los servicios de salud: um repaso integrativa de la literatura

 

 

Raquel Helena Hernandez Fernandes^I; Carla Aparecida Arena Ventura^I

^IUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil

 

 

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ABSTRACT

OBJECTIVES: To identify, analyze and synthesize scientific evidence on the relationship between the stigma existing in health services regarding alcohol users and illicit drugs and the self-stigma of these users.
METHOD: integrative review of the literature, through five distinct stages.
RESULTS: of the total of articles found in the databases, 07 were selected and analyzed, resulting in the categories "Public stigma in health services" and "The relationship between stigma in health services and self-stigma in alcohol users and illicit drugs".
CONCLUSION: self-stigma is influenced by public stigma propagated, mainly by authorities and health professionals. One of the alternatives to attenuate the scenario of self-stigma is social support.

Descriptors: Drug Users; Alcohol-Related Disorders; Self Stigma; Internalized Stigma; Health Services.

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RESUMEN

OBJETIVOS: identificar, analizar y sintetizar evidencias científicas sobre la relación entre el estigma existente en los servicios de salud en el que se refiere a los usuarios de alcohol y drogas ilícitas y el auto-estigma de estos usuarios.
MÉTODO: revisión integrativa de la literatura, por medio de cinco etapas distinguidas.
RESULTADOS: del total de artículos encontrados en las bases de datos, 07 fueron seleccionados y analizados, resultando en las categorias "El estigma público en los servicios de salud" y "La relación entre el estigma en los servicios de salud y el auto-estigma em usuarios de alcohol y drogas ilícitas".
CONCLUSIÓN: el auto-estigma es influenciado por el estigma público propagado, principalmente, por autoridades y por profesionales de salud. Una de las alternativas para atenuar el escenario del auto-estigma es el apoyo social.

Descriptores: Consumidores de Drogas; Trastornos Relacionados con el Alcohol; Autoestigma; Estigma Internalizado; Servicios de Salud.

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Introduction

When the use of alcohol and illicit drugs becomes a problem for society and promotes in its users socially unacceptable behaviors with a negative connotation, these are associated with an image of moral weakness, which can lead to their social exclusion⁽¹⁾, making them a vulnerable population group⁽²⁾.

Among the forms of exclusion of alcohol and illicit drug users, it is worth noting stigma, which is strongly related to prejudice, marginalization and eugenics. The word stigma was created by the Greeks to designate signs in the body made with cuts or fire to denounce that the person who had them was a slave, a criminal or a traitor and also to announce that this person possessed something bad. Stigma represents a social construction acting as a mark that attributes to one individual a devalued status relative to others⁽³⁾.

Stigma of alcohol and illicit drug users is associated with how society views this problem. Therefore, in a society in which alcoholism or illicit drug use has a strong moralizing connotation, social stigma becomes a major problem for users⁽¹⁾.

There are two strands of study on stigma related to the use of alcohol and other drugs. The first is linked to the understanding and study of how the process of stigmatizing and the strategies of change of perception from professionals and the users themselves on the use of alcohol are formed in order to promote resilient attitudes in the problem recovery. The other line of study establishes that social stigma reinforcement is seen as a benefit for control and recovery of alcohol and illicit drug users. In this perspective, there is an unformalized social punishment that seeks to convey the message that certain behaviors are not tolerated socially⁽⁴⁾.

In this context, stigma represents an important source of damages, especially in situations of job search and housing, which results in social isolation and often gaps in the use of health services⁽²⁾.

Moreover, some theorists argue that use/abuse of alcohol and other illicit drugs has had and still has repercussions in scenarios of non-assistance to users, stigma and prejudice, inadequate forms of treatment, family exclusion, social morality, association with leisure and crime⁽⁵⁾.

Thus, the moral attribution and blame of users of alcohol and illicit drugs by society can create barriers to the quality of health care, reinforcing their exclusion and suffering⁽¹⁾ and allowing the emergence of two main types of stigma that are interrelated: public stigma, which occurs when one group develops prejudice in relation to another group, and self-stigma, in which members of a stigmatized group internalize the public stigma⁽⁶⁾. Thus, users of alcohol and illicit drugs feel and are stigmatized by society and they self-stigmatize, which causes social isolation and can act as a barrier to medical and psychological treatments^(7-8) since these users internalize all the prejudices and exclusions from public stigma, being led to the belief that they are in fact morally condemnable and therefore not deserving any benefits, which places them social isolation.

It is therefore crucial to understand the phenomenon of self-stigma on the part of alcohol and illicit drugs users and thus find ways to cope with it as well as to minimize its consequences. This study aims to identify, analyze and synthesize scientific evidence on the relationship between stigma existing in health services regarding alcohol and illicit drugs users and self-stigma of these individuals.

 

Method

To achieve the objective of this study, an integrative literature review has been conducted to gather and synthesize preexisting knowledge about the relationship between stigma from health services regarding alcohol and illicit drug users and these individuals’ self-stigma through multiple surveys aimed at supporting discussions and general conclusions on this subject⁽⁹⁾.

The methodological course has taken place in five distinct steps: 1) formulation of the problem, 2) data collection or definitions on literature search, 3) data evaluation, 4) data analysis and 5) presentation and interpretation of results^(10-11).

Thus, the revision process guiding question was: What is the relationship between stigma from health services in relation to alcohol and illicit drugs users and their self-stigma? The question has been built through the so-called PICo strategy (P: patient or problem, I: intervention, Co: context)⁽¹²⁾, which consisted of: P (users of alcohol and illicit drugs), I (self-stigma), Co (stigma from health services).

Selection of articles occurred from electronic databases, among them, the CINAHL, which is an important base in the area of Nursing; APA PsycNET (American Psychological Association), which is a recognized foundation in the field of Psychology; Scopus, which is a multidisciplinary database and PubMed, for being the most important basis in international health.

In order to obtain the studies related to the topic proposed, qualification of the process occurred by searching keywords, since search by means of descriptors resulted in many articles that were not pertinent to the subject. The keywords used were "drug users", "substance use disorders", "alcohol-related disorders", "alcoholism", "self stigma", "internalized stigma", "substance-related disorders", "health services", "delivery of health care", "health care", "addiction", "alcohol drinking patterns", "drug abuse", "drug usage", "marijuana usage", "intravenous drug usage", and "substance abusers".

Inclusion criteria of studies were: articles published in English, Spanish and Portuguese languages, primary studies retrieved in databases from 1992 to 2015. Exclusion criteria adopted were the impossibility of acquiring the articles, those classified as editorials and those that did not correspond directly to the topic. Scientific articles were submitted to a preselection by means of readings of titles and abstracts in order to make up a set of studies associated with the guiding question.

 

Results

Integrative review

In all, 180 articles have been found. From reading titles and abstracts on CINAHL database, from 15 articles found, 3 were selected. On APA PsycNET, 108 articles were found, from which 8 were selected. On Scopus database, 47 articles were found and 3 articles were selected. Also, through PubMed database, 10 articles were found, with 1 article selected. From this preselection, by filtering the articles by means of readings and searches of articles repetition on databases, 8 articles were excluded, remaining 7 that were selected for reading in full. Figure 1 summarizes the search and selection phases of articles in this review.

The articles analyzed went through a survey that consisted of authors, title, journal, year, country, language, objective and level of evidence (LE)⁽⁹⁾, synthesized in Figures 2 and 3.

Prevalence of descriptive studies (level VI of evidence) recently published and in the English language is observed. During evaluation of studies, some aspects were categorized to facilitate the identification of those that were repeated.

As a final result, reading selected articles made it possible to visualize the process of self-stigma in alcohol and illicit drug users, divided into two aspects: public stigma in health services (health professionals) and the relationship between this stigma and the self-stigma in users of alcohol and illicit drugs.

 

Discussion

Public stigma in health services

Health services are organizations made up of health professionals that influence their internal and external actions. Studies selected suggest that these professionals can cultivate negative beliefs about people using alcohol and illicit drugs through ideas that these users use system resources that do not belong specifically to treatment and often do not adhere to recommended treatments^(13-14). Such perceptions can contribute to the unequal and poor provision of care for these people.

In this context, users may choose to hide their substance use problems to avoid stigma, which may result in care that does not meet substance use needs (e.g., during pregnancy)⁽¹⁵⁾. In addition, health professionals may refuse to offer certain services (e.g., needle exchange) or not prescribe effective pharmacological treatments to patients suffering from other diseases (e.g., cancer, back pain) because of stigma^(16-17).

Success in therapeutic treatment of these patients is rare, since relapse is routine and strongly influenced by stigma from health professionals⁽¹⁸⁾. Coupled with this, patients who return to treatment already started suffer more stigma and prejudice than those who are adhering to treatment for the first time⁽¹⁹⁾.

These findings reinforce the theory that public structural stigma comes from negative attitudes and behaviors of public institutions representatives, such as people working in health and criminal justice sectors, for example⁽²⁰⁾. Thus, it is possible to conclude that public opinion about the severity of use of alcohol and illicit drugs in a morally pejorative sense is also related to self-stigma, making it easier for users to internalize negative public opinions⁽²¹⁾.

Given this scenario, studies indicate that positive social support can reduce the negative impact of self-stigma due to the fact that alcohol and illicit drug users internalize as little as possible stigmatizing attitudes, which leads them to promote behaviors of coping and management of stigma⁽²²⁾.

Relationship between stigma from health services and self-stigma in users of alcohol and illicit drugs

Alcohol and drug users’ attitude of concealing use^(18,23) is one of the consequences of self-stigmatization, which makes it impossible for them to seek medical help, social services and social support⁽²⁴⁾. Thus, these people use self-concealment as a form of coping, that is, they prefer to go unnoticed by society⁽²⁵⁾.

In addition, users of alcohol and illicit drugs that internalize the stigma are depressive⁽²⁶⁾, avoid treatment, feel unable to seek employment and have poor interpersonal relationships⁽²⁷⁾. In this perspective, illicit drug users, specifically, have a large number of sexual partners and drug use partners, possibly because they understand each other and share discriminatory experiences they have undergone and undergo^(28-29).

In the same scope, illicit injection drug users who suffer from self-stigma feel more comfortable buying syringes at drugstores and not from public services⁽²⁴⁾. In addition, stigma and self-stigma may make it difficult for alcohol and illicit drugs users to achieve sobriety⁽³⁰⁾.

Also regarding therapeutic treatment, another significant aspect in self-stigma is that the higher it becomes and the greater the shame, the longer the treatment. This is due to the fact that alcohol and illicit drug users are afraid of what shall be addressed during treatment and of being judged by their behaviors and dependencies⁽³¹⁾.

There is a very close relationship between the categories identified. Thus, in order to illustrate the discussion and summarize the aforementioned categories, Figure 4 has been prepared.

 

Final thoughts

This integrative review identified few studies that analyzed the relationship between the stigma of health professionals and the self-stigma in users of alcohol and illicit drugs. Literature in this area is still scarce, which leads us to believe that there is a need for further research and studies that target the self-stigma in users of alcohol and illicit drugs.

In this sense, existing publications are significant in pointing out that self-stigma is greatly influenced by the public stigma propagated mainly by entities regarded as authorities and by health professionals, which include health services. These individuals and entities are social references, which makes the public stigma even more serious in these cases.

Faced with this negative public opinion, there is a belief that people who use alcohol and illicit drugs are not worthy of health care and thus the refusal to provide care and therapeutic treatment to these individuals arises. Even when there is no refusal, public stigma is so devastating a factor that when users of alcohol and illicit drugs feel stigmatized, they internalize the stigma, resulting in self-stigma.

One of the consequences of self-stigma is in alcohol and illicit drugs users’ fear of what shall be addressed during therapeutic treatment, which becomes ineffective, with a high rate of relapse, making it difficult for the user to achieve sobriety. Also in this scenario, self-stigma has as consequences the concealment of substance use and the difficulty of achieving healthy and dignified social and personal lives.

There are alternatives to improve the scenario of self-stigma and one of them is positive social support. If the user of alcohol and illicit drugs feels that he or she has some positive social support from family members, friends, health professionals and authorities, he or she may feel supported and welcomed and thus their therapeutic treatment may be effective. Thus, interventions in the groups above mentioned may demystify alcohol and illicit drug dependence, making social support prevail over stigma.

 

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Received: Jan 17^th 2017
Accepted: July 31^st 2018

Corresponding author:
Carla Aparecida Arena Ventura
E-mail: caaventu@eerp.usp.br
 https://orcid.org/0000-0003-0379-913X