Anti-stigma advocacy for health professionals: a systematic review

Figures & data

Table 1. Data extraction.

Author year country	Target	Level	Rationale	Theory base	Contents	Hours	Methods	Trainers
Allen et al. (2013) Australia	Nursing students	Interpersonal	Nurses are not able to directly overcome many structural barriers to health, such as poverty and low socio-economic status. However, nurses are able to provide culturally appropriate anti-discriminatory health care and understand the complex effects of the social determinants of health	Social constructivist model of health, (Baum, 2011) theory of transcultural nursing (Leininger & McFarland, 2002)	Knowledge on stigma and social conditionings of health, anti-stigma project, advocacy skills, direct contact (clinical placement).	72 h	Self-reflection, class discussion, small group discussion, case-scenarios, written assignment, clinical placement.	Faculty
Bakshi et al. (2015), USA	Medical students	Structural	Prioritizes engagement with local underserved communities, focusing on collaborations with community-based organizations Aims to equip the next generation of physicians with the ideals, peer support, knowledge, and skills to help eliminate health inequities through systems-level change	Social justice as defined by American Board of Internal Medicine	Human rights knowledge, condition knowledge, social justice knowledge, advocacy skills, career development knowledge, research skills.	8 weeks	Interactive lecture, class discussion, mentorship, personal projects (research and advocacy), practical experience (clinical rotation)	Faculty, expert speakers, older students
Boutain (2008) USA	Nursing students	Structural	The commitment to social justice is core in the nursing field There is a lack of evaluation of social justice in practice – there is a need for a tool to do so	Social justice	Social justice knowledge, advocacy skills, direct contact.	Not reported	Interactive lecture, essay writing, practical experience, self-reflection	Faculty
Burdett et al. (2010) UK	Nursing students	Interpersonal	Not reported	“Old people champion” program	Knowledge on stigma. Direct contact (speaker), indirect contact (video), advocacy skills, anti-stigma interventions.	6 hours	Simulation, case- scenario, small group discussions, poster presentation, video.	Trained faculty
O’Carroll and O’Reilly (2019) UK	GP	Interpersonal	It has been established that GPs who work with deprived or marginalised populations require context-specific knowledge and skills appropriate to the morbidity and mortality profile of those populations and that current medical education programmes fail to address these educational needs	Allport′s contact theory (Allport, 1954)	Knowledge on social determinants of health and trauma informed care. Self- care skills, direct contact (clinical placement), identify own bias skill, advocacy skills, recognize stigma.	128 h	Clinical placement, self- reflection, interactive lectures, theatre workshop, class discussion.	North Dublin GP training programme staff
Crawford et al. (2017) Australia	Occupational therapy students	Interpersonal, Structural	Client groups seen by occupational therapists do not have their rights fulfilled Occupational therapists require knowledge and confidence regarding human rights if they are to work effectively Occupational therapists can, and should, drive social change	Human rights (Hocking et al., 2021)	Human rights knowledge, Communication skills (including social media), cultural competence knowledge, advocacy skills, personal project.	13 wk	Interactive lecture, self-reflection, case-scenarios, anti-stigma project.	Faculty
DallaPiazza et al. (2018) USA	Medical students	Interpersonal	Teaching medical professionals about structural racism and how to recognize and address bias in clinical encounters has become increasingly imperative.	Jones Tripartite Model of Racism (Jones, 2000)	Knowledge on stigma, social determinants of health and trauma-informed care. Skills to address stigma, mnemonic frameworks to address personal unconscious bias and external microaggressions	11 h	Interactive lecture, small group case-based discussion, self-reflection, brainstorm, video	Faculty, student peers guided discussions
Delashmutt and Rankin (2005) USA	Nursing students	Interpersonal, structural	To be effective care givers, nurses must have an understanding of the complex nature of poverty, especially the multifaceted health challenges faced by the poor.	Empowerment	Knowledge on stigma, human rights and legislation. Direct (clinical placement, speaker), indirect contact (video) identify self-bias skill, advocacy skills.	32 h	Class discussion, interactive lectures, self-reflection, written assignment, video, clinical placement.	Faculty
Dharamsi et al. (2010) Canada	Medical students	Structural	Students should respond to the broader determinants of health by linking core concepts from the humanities and social sciences with the clinical and basic sciences. Help students appreciate first-hand the impact of social determinants on health outcomes	Canadian Medical Education Directions for Specialists (CanMEDS) health advocate role	Social determinants of health, applied advocacy skills	8 wk	Practical experience (over-seas placement), personal project, essay writing, self-reflection (reflective journal)	Faculty and clinical staff
Ezedinachi et al. (2002) Nigeria	Health workers at general hospital	Interpersonal	Health professionals should take the lead in the protection of human rights Addresses issues of stigmatization and human rights as integral to appropriate care of people with HIV disease, and the link between stigma and HIV	Not reported	HIV information, stigma knowledge, human rights knowledge.	2 d	Interactive lectures, role plays, small group discussion, group discussions, videos.	Experts, influential role models trained in initial workshops.
Fisher et al. (2017) USA	Social workers	Interpersonal	Not reported	Biopsychosocial factors under racism. Interracial interaction (Kratzke & Bertolo, 2013; Sue et al., 2009) microaggressions (Boysen, 2012)	Knowledge on stigma and biopsychosocial model of health. Anti- stigma skill.	3 h	Small group discussion, class discussion, role play, brainstorming	Multiracial facilitators
Fisher-Borne (2009) USA	Health care professional (Disease intervention specialist)	Interpersonal	A key strategy in addressing health disparities is promoting cultural competency among health professionals.	Theory of cultural humility, Campinha-Bacote model of cultural competence (Campinha-Bacote, 1999)	Knowledge on race, MSM/LGBT, cultural competence and stigma. Identify own bias, advocacy skills, communication skills, indirect contact (video), direct contact (speaker). Resource manual with LGBT specific local and state-wide resources	16 h	Role playing, case-scenarios, brainstorm, self-reflection, dynamic, paired-sharing.	Project STYLE staff
Flatt-Fultz and Phillips (2012) USA	Healthcare professional working with people with intellectual disabilities	Interpersonal	Empowerment is the first important step for agencies that support people with intellectual and developmental disabilities. Training focused explicitly on empowerment was not investigated before	Cattaneo and Chapman empowerment (Cattaneo & Chapman, 2010)	Indirect contact (video)	0.5 h	Video, group discussion.	Not reported
Geibel et al. (2017) Bangladesh	Healthcare professional working in sexual and reproductive health and rights	Interpersonal	Working with health providers to reduce stigma and discrimination in the healthcare setting is one strategy to improve service utilization and quality of care	Not reported	Knowledge on stigma, human rights and HIV. Advocacy skills at an interpersonal and structural level.	24 h	Interactive lecture, group discussion, self-reflection, use of pictures, game, role-play, personal project.	Specialized trainers (Link up project)
Gonzalez et al (2015) USA	Medical students	Interpersonal, Structural	Curricula which instructs students on reducing health disparities both within clinical practice and within their communities. Promote medical students’ awareness of their own potential to contribute to health disparities and to provide them with clinical and advocacy skills to reduce systemic causes of health disparities.	Not reported	Anti-stigma project, advocacy skills, health disparities knowledge, social determinants of health knowledge, implicit bias knowledge (IAT test), communication skills, Advocacy skills (strategic planning, grassroots organizing, meeting with legislators, and media communications)	19.5 h	Interactive lectures, group discussions, role play, small group discussion, case scenarios, personal project.	Faculty
Gonzalez et al. (2020) USA	Medical students	Interpersonal	Curricula usually emphasize increase awareness of implicit bias but don’t provide opportunities for skill development and practice.	Conceptual framework by Teal and colleagues explaining individual’s progression through various stages related to IBRM (Teal et al., 2010)Transformative learning theory.	Implicit bias knowledge, implicit bias recognition skills, communication skills, advocacy skills, address biased comments skills in clinical and teaching encounters, skills to manage own bias.	13.5 h	Interactive lecture, contact, videos of popular culture, write personal narratives, self-reflection on students own implicit bias and lived experience, race implicit association test, debrief, case-scenarios, recorded role-play with “do-over”, brainstorm.	Not reported
Griffith and Kohrt (2016) USA	Psychiatry residents	Interpersonal	Not reported	Social psychology and social neuroscience	Knowledge on stigma and recovery. Anti-stigma project, skill aid coping with stigma skill, framework for anti-stigma strategies.	12 h	Small group discussion, interactive lectures, case- scenarios, role-play, readings, games	Faculty
İnan et al. (2018) Turkey	Nursing students	Interpersonal	Nurses who are in contact with patients, their relatives, and other members of society have the opportunity to be role models for creating positive attitudes.	Not reported	Knowledge on mental illness and stigma. Direct contact (placement, visit) and indirect contact (video). Anti-stigma campaign. Skills on communication and aiding in coping with stigma.	32 h	Group discussion, interactive lectures, personal project, videos, article review. Clinical placement and observership	Faculty and stigma expert
Jindal et al. (2022) USA	Pediatric residents	Interpersonal, structural	Medical education should build provider knowledge and capacity to address racism.	Not reported	Self-reflection and implicit bias, historical trauma, structural racism,	1 h	Interactive lecture, group discussion, role-playing	Faculty
Jones and Smith (2014) USA	Nursing students	Structural	The American Association of Colleges of Nursing (2008) states that advocacy “is a fundamental aspect of nursing practice”. Preparing nurses for leadership in areas of advocacy and policy development allows them to develop a vision for how nurses contribute to creating healthy communities.	Not reported	Knowledge on health disparities, human rights, social justice and marginalized populations. Advocacy skills. Assignment on advocate for current issue affecting vulnerable population (policy statement). Indirect contact (video)	Nor reported	Group discussion, interactive lecture, class presentation of assignment, video	Faculty
Knaak (2018) Canada	Nurses in general hospitals	Interpersonal, Structural	Healthcare professionals can be stigmatizing Healthcare professionals report that they lack the skills to help someone with a mental health issue, which also contributes to stigma.	Not reported	Stigma knowledge, strategies to address stigma, recovery model knowledge, social determinants of health knowledge, advocacy skills.	Not reported	Self-reflection, case-scenarios, web-based.	Not reported
Lax et al. (2019) USA	Residents	Interpersonal, Structural	Needs assessment showed that healthcare professionals do not know how to address social determinants of health Pilot study: Implementation of an advocacy teaching- module enabled residents to screen for and document social determinants of health consistently	Health advocacy (Wright et al., 2005)	Advocacy skills, framework, community resources, legislative knowledge.	Not reported	Case-scenarios, interactive lectures, class discussion, case-scenarios, interactive lectures, small group discussion, practical experience.	Faculty-resident pair. Experts speaker guests.
Li et al. (2013) China	Health care professional in general hospital	Interpersonal, structural	Stigma in the general population has been well‐documented, but its impact is also felt in healthcare settings, where it can lead to testing avoidance, barriers to health counselling and a lack of adherence to antiretroviral therapies.	Not reported	Knowledge on HIV and stigma, indirect contact (video), communication skills, advocacy skills, identify bias.	10.5 h	Group discussion, games, role- playing, pair-sharing, demonstrating, case- scenarios, video.	Trained local health educators, AIDS specialists, project staff
Li et al. (2015) China	Community mental health staff	Interpersonal	Interventions are needed to address the stigma of mental healthcare professionals	Not reported	Condition knowledge, public health knowledge, stigma knowledge, legislative knowledge, rehabilitation knowledge.	14 d	Clinical practice, interactive lectures.	Not reported
Mason and Miller (2006) USA	Social work students	Interpersonal	Students need an in-depth under- standing of mental health disorders so they may provide balanced and focused treatment for each client’s unique abilities and growth potential.	Not reported	Knowledge on stigma. Indirect contact (video), direct contact (clinical placement in group and individual sessions targeting auto-stigma with patients), skills to aid coping with stigma, recognize own bias, social isolation.	Not reported	Interactive lecture, role play, group discussion, educational videos, clinical placement.	Faculty
McAllister (2008) Australia	Nursing students	Interpersonal	Clinicians need cultural and social skills to influence public opinion, enhance tolerance, deepen understanding, explode myths, and work to effect social change. critical literacy is an important cognitive skill, effective in raising consciousness about inequity and injustice.	Critical literacy	Knowledge on mental health, social justice, and stigma. Skills on advocacy and critical literacy, indirect contact (video), framework for critical literacy	120 h	Interactive lectures, readings, video, textual analysis of different sources (musical representations, film, news).	Faculty
Nelson et al. (2015) USA	Medical residents	interpersonal	Physicians receive little to no training on the topic of race and racism, yet this is one of the largest barriers to health equity.	Not reported	Knowledge on stigma. Advocacy skills, identify own bias skill. Framework ("interrupt and educate") for addressing racism, commitment to address racism.	6 h	Group discussion, interactive lectures, video.	Faculty
Potts et al. (2022) UK	Medical residents	Interpersonal	Healthcare professionals should be a main target of anti-stigma campaigns as they can be highly stigmatizing towards their patients, however healthcare professionals could also be those who aid anti-stigma efforts	Recovery oriented	Knowledge on stigma, anti-stigma skills, direct (speaker)	2.5 h	Interactive lecture, group discussion, video	Psychiatrist, people with lived experience
Üstün and İnan (2018) Turkey	Nursing students	Interpersonal, systemic	Knowledge transmission on stigma is not enough, there is a need to use different educational methods to raise awareness and impart change.	Not reported	Anti-stigma project, stigma knowledge, identify own bias skills.	16 h	Personal project, class discussion, video, interactive lectures, case-scenario, brainstorm	Not reported
Shah et al. (2014) India	Nursing students	Interpersonal	Across multiple studies, stigma toward PLHIV has been found to be high among health care workers, including nurses and ward attendant	Not reported	Knowledge on HIV and stigma. Direct contact (speaker), strategies to decrease stigmatizing behaviours in hospital.	2 h	Interactive lecture, brainstorm, group discussion.	4th year medical student, PLHA
Sheely-Moore and Kooyman (2011) USA	Mental health students	Interpersonal, structural	It is imperative for counsellor educators and trainers of mental health professionals to infuse instructional strategies that promote multicultural and social justice competencies for trainees.	Multicultural competences (Arredondo et al., 1996). Lee’s (2018) model of self- exploration for social justice.	Knowledge on stigma, anti-stigma project, direct contact (visits), advocacy skills, identify own stigma.	Not reported	Class discussion, self- reflection, modelling, case scenarios, role play, simulation, videos, obervership.	Faculty
Sherman et al. (2019) USA	Family medicine residents	Interpersonal, structural	There is a need for a health professionals curriculum that will move beyond simply identifying implicit biases through self-reflection to (a) provide insight into how such insidious biases perpetuate institutional inequities and potentially exacerbate structural racism, and (b) empower health care professionals with skills for managing instances of racism and other implicit biases in their professional lives.	Not reported	Knowledge on race-culture, stigma and implicit bias. Emotion regulation skills, commitment, self bias recognition skill, tools to address barriers for health care.	1.5 h	Interactive lectures, group discussion, self-reflection, video.	National experts on implicit bias
Sukhera et al. (2020) Canada	Health professionals	Interpersonal	Traditional stigma reduction education programs often fail to confront the implicit nature of stigmatizing attitudes.	Implicit bias	Knowledge on stigma. Communication skills, identify own bias skills, “facilitating awareness through dissonance” dynamic.	4 h	Interactive lecture, group discussion, small group discussion, role play, case-scenario, self-reflection, debrief	Physician and nurse facilitator
Tucker et al. (2020) USA	Medicine students	Interpersonal	It is key to understand the impact of mental illness on individuals and their families and increase patient-centered and collaborative care in emergency and routine practice settings	Not reported	Understanding the experience of mental illness, supporting predictable emotions and needs, empathy’s role in effective treatment, psychological elements of collaborative care, and applying collaborative treatment principles	15 h	Interactive lecture	It is led by a team of three trained facilitators, as follows: (1) a person living well in recovery from SMI, (2) a family member of someone with SMI, and (3) a healthcare provider with personal or family experience with SMI.
Uys et al. (2009) Lesotho, Malawi, S. Africa, Swaziland Tanzania	Nurses	Interpersonal	Not reported	Empowerment by Cross and Choudhary (Cross & Choudhary, 2005)	Knowledge on stigma, anti-stigma project, direct contact (develop project together), aid coping with stigma skills, advocacy skills	24 h	Group discussion, interactive lectures, person project	Nurse, PWLA
Wagaman et al. (2019) USA	Social work students	Interpersonal, structural	Transformational models of teaching and learning are needed to explore and expand the preparation of students to address race and racism in practice	Critical race theory (Abrams & Moio, 2009) , liberation theory (Brigham, 1977)	Knowledge on stigma and social justice. Recognize own bias, direct contact (community visit), advocacy skill, commitment, resources to extend work in community.	8 h	Interactive lecture, small group discussion, brainstorm, self-reflection, group discussion, observership.	Community worker
Webb and Sergison, (2003) UK	Health care and social worker in child health services	Interpersonal	Not reported	Not reported	Knowledge on race and stigma. Empathy skills, communication skills, indirect contact (video).	8 h	Case scenarios, videos, interactive lectures, group discussion.	Multidisciplinary group, experts in antidiscrimination
Werkmeister Rozas and Garran (2016) USA	Social work students	Interpersonal, structural	Recently, in the USA, there have been more concerted efforts to infuse human rights throughout social work curricula and, as a result, there is a call for ways to evaluate and/or measure student outcomes	Not reported	Knowledge on stigma, advocacy skills, anti-racism project, identify stigma skills	Not reported	Interactive lectures, class discussion	Faculty
White-Davis et al. (2018) USA	Healthcare professionals	Interpersonal	While teaching health care professionals about racism reduces biases, few curricula. for medical education exist.	Jones Tripartite Model of Racism (Jones, 2000)	Knowledge on stigma. Anti-racism commitment. Toolkit for exploring racism.	1.5 h	Interactive lecture, small group discussion, case-scenario, group discussion, video	Multicultural health faculty (multiracial, multidisciplinary team)
Wu et al. (2019) USA	Healthcare professionals of various settings	Interpersonal structural	Even if individual health care professionals are knowledgeable, institutional support is needed to facilitate constructive discourse and enact broad change. Without foundational knowledge and institutional policies, trainees and providers can be subject to a “silent curriculum” of the health care system, in which biased behaviours and values are internalized and perpetuated	Anti-oppressive practice (Larson, 2008) social justice (Sensoy & DiAngelo, 2012) Jones Tripartite Model of Racism (Jones, 2000)	Stigma knowledge, advocacy skills, identify own bias skill, compassion, emotion regulation skill, anti-racism commitment. Step up/step back framework for addressing racism.	3 h	Small group discussion, interactive lectures, group discussion, brainstorm, case- scenarios, self-reflection, interactive activities	2 authors
Zäske et al. (2014) Germany	Mental health providers at psychiatric hospital	Interpersonal	There is a strong power dynamic between psychiatric staff and patients. Which may lead to high levels of institutional stigma. It is important to work with psychiatric staff as they can become role models both within and outside of their institution when it comes to detecting and addressing stigma	Not reported	Knowledge on stigma and professional role, direct contact (speaker), anti-stigma skills.	16 h	Role playing, group discussion, interactive lectures, short- essay writing.	Trainer experienced in education and people with lived experience

Table 2. Efficacy outcomes

Reported by target population	Zaske et al.	Inan et al.	White-Davis et al.	Potts et al.	Li et al.	Wu et al.	Fisher-Borne et al.	Allen et al.	Nelson et al.	Uys et al.	Shah et al.	Geibel et al.	Sukhera et al.	Li et al.	Lax et al.	Knaak et al.	Gonzalez et al.	Ezedinachi et al.	Tucker et al.
Attitudes
Social distance	↙	↙																	↙
Commitment to personal change			↑
Attitude towards condition/characteristic				↑			→	→		→		↑	↑	↑*	→	↑	↑	↑
Endorsement of coercive policies											↑
Willingness to provide care												↑ *
Knowledge
Knowledge of stigma			↑	↑		↑	↑		↑					↑^			↑
Policies against discrimination												↑
Self-confidence
Confidence in practicing trans-cultural nursing								↑
Confidence in addressing discrimination			↑												↑		↑		↑
Behaviour
Discussing stigma	↑				↑						↑
Discriminate when dispensing medication
Discriminate when drawing blood											→
See PLHIV as a client												↑
General reported and intended behaviour														↑^
Advocating self-reported practices															↑
Skills
Ability to deliver care				↑			→		↑									↑
Identify discrimination	↑					↑												↑
Address discrimination	↑		↑			↑	→
Managing prejudice situations	→					↑
Reported by observers
Perceived stigma reduction					↑
Improvement in equal treatment					↑
Reported by stigmatized population
Perceived stigma										↑		↑
Satisfaction with quality of care										↑		↑
Self-stem										↑
Self-efficacy										→
Report discussing stigma with provider												↑*

Key: * = at 6 mo. ^ = at 6 and 12 mo. ↑ increase → constant ↙ decrease

Figure 1. PRISMA flow diagram.

Table 3. Acceptability outcomes.

Author year country	Design	Sample size	Sampling	Nature of intervention	Timing of outcome measurement	Acceptability outcome	Response rate
Burdett et al. (2010) UK	Cross-sectional	325	Convenience	Mandatory academic activity	Post-intervention	•70% rated the session excellent. •56% thought the structure was excellent, 42% thought it was good. •66% rated content as excellent, 33% as good. •100% would recommend the session.	Not reported
DallaPiazza et al. (2018) US	Cross-sectional	536	Convenience	Mandatory academic activity	Post-intervention	•63% agreed to a great and 26% to a moderate degree that they felt more comfortable using concrete tools delivered. •71% agreed to a great and 21% to a moderate degree that additional training on this topic would be beneficial. •72% felt objectives had been met considerable/in very high degree.	30–41%
Knaak (2018) Canada	UPPI	198	Self-selected convenience	Voluntary	Post-intervention	•87.6% strongly agreed or agreed the program addresses their learning needs. •93.8% strongly agreed or agreed it was relevant to their practice. •92.2% strongly agreed or agreed it enhanced their knowledge in the area. •78.1% strongly agreed or agreed they would recommend it.	77.16%
Shah et al. (2014) India	CPPI	91	Convenience	Mandatory academic activity	Post-intervention	•89–100% rated it as useful and easy to understand. •95% felt it will change their practice and would recommend it. •9–22% reported some of the materials made them uncomfortable. •38–40% report feeling embarrassed to share their opinions. •87–93% felt they could be honest about their beliefs.	100%
Sherman et al. (2019) US	Cross-sectional	31	Not reported	Not mentioned	Post-intervention	•88% qualified it as excellent and 13% as very good. •100% would strongly recommend it.	100%
Webb and Sergison, (2003) UK	Cross-sectional	140	Self-selected convenience	Voluntary	Huddersfield: Post-intervention Cardiff: 2–7 years post-intervention	Huddersfield: •98% rated the course as good or excellent. •75% said training met most to all of their needs. •99% stated the course outcomes were achieved. •96% were satisfied/very satisfied with the practical info given. •21% said they would like further training Cardiff: •83% rated the course as relevant or highly relevant. •79% said this was the first such training attended. •52% felt they would like further training.	Huddersfield: 97%, Cardiff: 62%

CPPI: controlled pre-post study.

Figure 2. Intervention contents and delivery methods frequencies.

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Data Availability Sstatement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.