Stigmatized Patients

What is a stigma?
 Stigma refers to attitudes and beliefs that lead people to reject,
avoid, or fear those they perceive as being different.

 Stigma impairs an individual’s and their caregiver’s physical, social

and emotional wellbeing, and health-seeking behavior.

Public stigma:
• “Public Stigma” refers to the attitudes and beliefs of the general
public towards persons having stigmatized diseases or their family
members.

• Nepali society is very conservative and orthodox which has

contributed to different social stigmas prevalent in the country.

Self-stigma:
• “Self-stigma” occurs when an individual buys into society’s
misconceptions about different diseases like mental illness, TB,
leprosy, STDs, cancer, etc. By internalizing negative beliefs,
individuals or groups may experience feelings of shame, anger,
hopelessness, or despair that keep them from seeking social
support, employment, or treatment for their mental health
conditions.
Discrimination:
• While “stigma” is an attitude or belief, “discrimination” is
behavioral changes because of those attitudes or beliefs.

• Discrimination occurs when individuals or institutions unjustly

deprive others of their rights and life opportunities due to stigma.
Discrimination may result in the exclusion or marginalization of
people and deprive them of their civil rights, such as access to fair
housing options, opportunities for employment, education, and
full participation in civic life.

Who are Stigmatized Patients?

• Stigmatized patients are those who are suffering from diseases
which have social stigmas and are not easily accepted by the
society.

• There are a number of diseases that are stigmatized – mental

disorders, AIDS, venereal diseases, leprosy, and certain skin
diseases.

• People who have such diseases are discriminated in the health

care system and they usually receive much less social support
than those who have non-stigmatizing illnesses.

• They have great difficulties in organizing their life if their disease

has caused impairment.
Most common Stigmatized Patient in Nepal
I. TB Patient

II. Leprosy Patient

III. STDs Patient

IV. Cancer Patient

V. Mental Disorder Patient

I. Tuberculosis

• It is a contagious infection caused by Mycobacterium tuberculosis

that usually attacks the lungs.

• It can also spread to other parts of the body, like the brain and
spine.

• It is still considered to be one of the major public health problems

of Nepal and estimated that 44,000 new infections occurs
annually and accounts for 5000-7000 life lost.

• The disease is spread in the air when people who are sick with
pulmonary TB expel bacteria, for example by coughing. 

• In Nepali society, Tuberculosis has been and is still considered as a

‘dirty disease’, ‘a death penalty’ or as affecting ‘guilty people’ and
also considered to be an inherited and/or incurable disease
associated with unclean or undesirable habits or livelihoods
II. Leprosy
• Leprosy is a chronic disease caused by Mycobacterium leprae.

• It is not highly infectious but can cause severe and permanent

damage to the skin, nerves, limbs and eyes resulting to
disfigurement and deformities if untreated.

• A data shows that 3,000 new leprosy patients are reported in the
Nepal every year.

• A total of 175,000 leprosy patients are receiving treatment across

the world, while 2,500 such patients are undergoing treatment in
Nepal.

• Hindu culture has viewed leprosy as a punishment for past

misdeeds, and even in the Christian mindset, the idea of leprosy
has been strongly coloured by the biblical references in the Old
and New Testaments – uncleanness possibly resulting from a
curse from God.

• Leprosy is perceived in many village communities as a punishment

for misdeeds in a former life.

• People with leprosy are often ostracized by their communities,

reporting complete rejection or banishment by communities,
insults and hate.

III. Mental Disorders

• A mental disorder or psychiatric disorder is a behavioral or mental
pattern that causes significant distress or impairment of personal
 functioning and such features may be persistent, relapsing and
remitting, or occur as a single episode.

• Mental health problems are increasing in the Nepal with 2 per

cent of the country’s total population suffering from mental
diseases while 5 per cent of the population suffers due to mental
problems.

• Due to inaccuracies and misunderstandings, people have been led

to believe that an individual with a mental illness has a weak
character or is inevitably dangerous.

IV. Cancer
• According to data, 27,800 people are newly diagnosed with
cancer per year in Nepal and 20,000 people die annually due to
cancer.

• Incidence of cancer in Nepal is growing at a higher rate for both

males and females.

• The most common cancers in males are bronchus and lung,

stomach and larynx while in females cervical uteri, breast,
bronchus and lung are the most common cancers.

• There are several reasons that cancer is stigmatized.

• Many people in our area perceived cancer to be a fatal disease.

• Cancer symptoms or body parts affected by the disease can

cultivate stigma.
 • Fears about treatment can also fuel stigma.

• People also have belief that cancer is contagious, or cancer may

be seen as a punishment.

V. STDs
• Human Papillomavirus, Chlamydia, Gonorrhea, Syphilis, Herpes,
Trichomoniasis, HIV/AIDS are the common sexually transmitted
diseases.

• STD infections are on the rise among the Nepalese.

• HIV/AIDS, syphilis are more stigmatized disease in Nepalese

society.

• People think that STDs are caused because of patient’s lack of

moral integrity and values of a person.

• People having STDs are not only stigmatized by others but they
also stigmatize themselves due to perceived stigma or experience
of discrimination, which can have serious consequences, such as
low self-esteem, depression and self-isolation.

• Stigmatization, delayed treatment-seeking, and unwillingness to

notify spouses and sexual contacts are important issues in STD
prevention and control. 

• The perception of stigma blocks the acceptance of community

prevention efforts among people at risk and reduces the
probability that they will inform their sexual contacts. 
• HIV infection is commonly perceived as the result of a personal
choice – one chooses to engage in ‘bad’ or ‘immoral behaviors’.

• For long time, HIV has been portrayed as a killer disease with no
treatment

• HIV AIDS was initially perceived as an STD and a "homosexual"

disease and is associated with behaviors that are considered
illegal or forbidden in most societies such as extra-marital sex, sex
work, drug use and sex between men.

• Syphilis was regarded as capable to produce a race of degenerate

children or as a serial killer in late 80s. People suffering from
syphilis were considered religiously impure and were not allowed
to be priests in churches in Europe.

• Syphilis was regarded as capable to produce a race of degenerate

children or as a serial killer in late 80s. People suffering from
syphilis were considered religiously impure and were not allowed
to be priests in churches in Europe.

• The impact of STDs related stigma and discrimination is not

limited to lowering the quality of life of people suffering from
STDs, but it also is a barrier in responding to STDs epidemic
effectively.

• Fear of discrimination prevents people from utilizing STD

prevention services and prevents people from seeking treatment
for STDs or disclosing their status openly. This increases further
STD transmission and exacerbates impacts of STDs.
Role of pharmacist in the care of stigmatized patients
• Pharmacists are the medication experts and it's their
responsibility to make sure patients have all the information they
need. In case of stigmatized patients they have special role to
play.

• Pharmacist should never implicit any kind of bias or stigma

toward any patients. This is where pharmacists’ open and non-
judgmental attitude important.

• Pharmacists in co-operation with other health care professionals

should try to minimize stigma, with the goal of improving access
to care for stigmatized patients. This can be started by proper
counseling to the family members of stigmatized patients
regarding the misconceptions of the diseases, etc.

• Stigmatized patients should be offered respect, empathy,

compassion, help to seek support when needed, and a sense of
hope, as one of the most disabling aspects of stigmatized diseases
is the perception of exclusion from ordinary activities and
treatment by the community as a whole.

• Specifically, pharmacists can offer measures to improve patient

education, medication adherence, concordance and behavioral
prompts, as well as monitoring medication use.

• In case of mentally ill patients, pharmacists can also promote new

programs that equip people to look after their own mental health.
 •  Patient education involves dispelling misconceptions of
stigmatized diseases, providing personalized and explaining the
details regarding the impact of particular medicines.

• Privacy and confidentiality of patient has to be maintained and

respected by the pharmacist.

• Stigmatized patients counseling should be done in a separate

room and not in public so that the patient feels comfortable and
actively participates in counseling.

• Counseling should provide adequate information about their

disease, drug therapy, etc.

• Pharmacists can direct stigmatized patients to useful resources

and support organizations.

References:
• https://www.researchgate.net/publication/254892309_HIV_and_AIDS_re
lated_stigma_and_discrimination_in_Nepal [accessed Mar 26 2018].

• https://www.google.com.np/np/amp/s/www.psychologytoday.com/us/b
log/whyweworry/201308/mental-health%3famp