Browsing by Subject "Stigma"

Problem and Purpose: Arab adolescents are considered a particularly vulnerable population to depression. The substantial lack of mental health services and the stigma associated with mental illness on the one hand; and poverty, unemployment, and lack of reasonable hopes for a decent future in the context of corruption of regimes and perceived social injustice on the other, call for establishing committed and effective policies to tackle depression and its associated stigma among Arab adolescents at risk for or diagnosed with depression. However, there is a substantial lack of research that can inform the current profile of adolescent depression in the Arab region. We conducted two systematic reviews on Adolescent depression and mental illness stigma in the Arab region and found that there is currently no solid evidence available on the prevalence of depression among Arab adolescents and its potential associations with depression stigma and help-seeking beliefs and intentions. This gap in the literature makes it difficult to design, implement, and disseminate effective interventions to improve the prevention, diagnosis, and treatment of adolescent depression. Therefore, the overarching purpose of this study was to estimate a prevalence of depression symptoms among Arab adolescents, and determine relationships with depression stigma, depression etiologic beliefs, and likelihood to seek help for depression.

Methods: This study was conducted in Jordan, a Middle Eastern Arab country. A pilot study with a sample of 88 Jordanian adolescents was first conducted to assess the feasibility of collaboration and coordination with the proposed recruitment sites; assess proposed recruitment strategies; confirm the utility of the translated self-reported measures and examining their psychometric properties; and obtaining preliminary findings. Based on the lessons learned from this pilot study, we designed a nationally representative, school-based survey. Data were collected from 2,349 adolescents aged 12-17, using a packet of self-administered questionnaires that included measures on sociodemographic and health history, depression severity, depression stigma, depression etiologic beliefs, and likelihood to seek help for depression. A passive consenting procedure was used to obtain parental consents, while returning the survey questionnaires was considered a tacit assent for the adolescents. The study obtained the needed Institutional Review Board approvals from both Duke University and the University of Jordan. Participants represented all three regions in the country, with 34% from the northern (suburban) region, 43% from the central (urban) region, and 23% from the southern (rural) region.

Results: The majority of the adolescents were females (59%) and 15-17 years old (67%). Almost 14% reported having at least one chronic health problem, 15% reported having a mental health problem, 25% reported having academic difficulties, 8% reported that they had received a psychiatric diagnosis, and 22% reported that they had sought psychological help at some point in the past. The mean total depression score was 16.3 (SD=11.2, 95% CI=15.8 to 16.7), with 34% of the sample reporting moderate to severe depression. Depression was significantly higher among respondents who were female, ages 14-15 years, and living in families with monthly incomes less than JD300 (USD 423); and who reported having a chronic health problem, mental health problem, learning difficulty, a psychiatric diagnosis and/or seeking previous psychological help. Adolescents endorsed multiple etiological factors for depression. The most often reported factors were stressful events in one’s life (72%), social factors (65%), and one’s weak will (56%). On the other hand, the least reported factors were genetic or inherited problems (24%), chemical imbalance (30%), and punishment for wrong doings (35%). Adolescents were more likely to seek help for depression from a family member (57%), followed by a counselor (46%), psychiatrist (43%), religious leader (39%), and general practitioner (28%). In addition, 53% of the adolescents reported they will be willing to take medications for depression, while 50% expressed willingness to seek a therapy, and 25% of the adolescents reported they will not be willing to seek any professional help for depression. Almost half of the adolescents agreed on items that reflect stigmatizing attitudes towards depression. Adolescents reported higher rates of perceived depression stigma than personal depression stigma. Depression stigma was not significantly associated with the adolescent’s severity of depression, but with adolescent’s sex, age, region of residence, parents’ education, and history of mental health problem.

Conclusions: This study revealed alarming results in terms of the current high prevalence and social determinants of adolescent depression in Jordan. The study also shed light on how depression stigma manifests among Jordanian adolescents and how such stigma relates to their beliefs about depression and likelihood to seek professional psychological help. We discuss how healthcare providers, researchers, and educators can focus attention on developing effective and culturally appropriate screening, prevention, and intervention approaches using evidence-based guidelines to promote Jordanian adolescent mental health, particularly for depression. This approach will be important not only for Jordan, but for all of the Arab region, given that many of the Arab countries have been witnessing years of mass violence, armed conflicts, and war. The study also provides important recommendations on when, how, and why to utilize school settings for anti-depression stigma interventions. Overall, findings from this study provide a solid, culturally competent foundation from which to conduct future research to tackle depression and its associated stigma, and reflect the unique characteristics of Arab culture.

Background: The Cataldo Cancer Stigma Scale (CASS) was developed to measure patient experienced and perceived stigma and was further modified for use in the pediatric patient population. This study aimed to adapt and translate a Swahili version of the CASS for use in the Tanzanian pediatric patient population to measure cancer stigma and identify the types of stigma pediatric cancer patients face. Methods: Approximately 40 items were extracted from two prior developmental and validation studies of the CASS that assessed stigma in adult patients and non-patient cohorts. The survey items, developed initially in English, underwent translation into Swahili, back-translated, reconciled, and screened for duplications. The translated items were refined using concurrent cognitive interviewing. Results: After three rounds of cognitive interviews with 15 respondents, comprehension of the survey questions was assessed and improved with all items reaching at least 80% comprehension. Additional reviews included grammar and specific Swahili word selection changes to clarify the question’s meaning. Duplications or repetition of sentences were also considered to remove questions from the survey. The final survey comprised 25 survey items with 7 stigma sub-categories. Conclusions: This study sheds light on the complex nature of cancer-related stigma in pediatric patients. For future purposes, research is needed to validate the CASS survey with a larger sample of the population, including a comparison stigma assessment to establish validity.

Researchers have been searching for ways to improve outcomes for orphaned and separated children (OSC) worldwide. OSC have a particularly high rate of mental health disorders and lower emotional wellbeing. Stigma has been shown to be a predictor of mental health disorders and emotional wellbeing for HIV and children in poverty. However, no research has been conducted with OSC examining the relationship between self-stigma and emotional wellbeing. Using Round 10 of the Positive Outcomes for Orphans (POFO) study with 2013 orphans from Kenya, Ethiopia, Tanzania, India, and Cambodia, a linear model was implemented to examine the association between self-stigma and emotional wellbeing. Through the building of a linear regression model, self-stigma was shown to be a strong predictor of emotional wellbeing as measured by the Strengths and Difficulties Questionnaire (SDQ). This indicates that self-stigma may be a significant factor to address when looking at ways to improve emotional wellbeing among orphans.

Extensive evidence demonstrates how mental illness symptomatology can inhibit perceptions of and actual performance on important tasks. However, receiving treatment from the medical establishment for such symptomatology requires diagnosis, whereby the patient becomes labeled and subject to the stereotypes connected to that label. Mental illness labeling is associated with a variety of negative outcomes including inhibited access to unemployment, housing, health insurance, and marriage and parenthood opportunities and can disrupt interpersonal relationships. However, the repercussions of mental illness labeling for one area of life have remained largely overlooked; that area is task performance. Adults spend a substantial portion of their lives at work engaged in group-based or individual level tasks. This dissertation explores external perceptions of mental illness in task groups and the role of self-internalization of stereotypes about mental illness in individual task performance through two experimental studies.

Previous research has revealed that, on average, task partners with a mental illness are stigmatized and subject to diminished status when they are identified to participants as having been hospitalized for general psychological problems for an extended period of time. Study 1 of this dissertation explores the stigma- and status-based attributions triggered by engaging with a partner in a mutual task who is identified as having a specific mental illness label: none, Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), Attention-Deficit/Hyperactivity Disorder (ADHD), or schizophrenia.

Additionally, research has revealed that members of a group about which negative stereotypes exist may face a situational threat in a domain relevant task--stereotype threat. Race, gender, social class, age, and a variety of other sociodemographic attributes can trigger stereotype threat. However, little research has considered the potential for stereotype threat to emerge on the basis of mental illness labeling. Study 2 of this dissertation focusing on individual-level performance, exploring the potential for ADHD to trigger stereotype threat in test-taking situations.

Results from Study 1 suggest that the specific mental illness labels studied, presented devoid of symptomatology severity, do not trigger stigmatized attributions but may trigger some negative status attributions in the case of a task relevant diagnosis. (ADHD). Study 2 suggests that a task relevant diagnosis may also trigger stereotype threat in a test-taking situation, negatively impacting performance. Taken together, the results indicate that task relevance of one's mental illness label may be a driving factor in negative external and internal perceptions of mental illness.

This dissertation aims to investigate the ways in which culture shape how people perceive, remember, and transmit information to one another and how that information can be shaped by culture. I specifically study: (1) how stigma and stereotypes affect how individuals discern and recall information about an individual with schizophrenia; and (2) how political partisanship may alter one’s perceptions of an ambiguous social interaction that is politically salient. To answer these questions, I conduct two experiments and collect data from online participants. In the first study, I recruit participants from Amazon Mechanical Turk to read a story about an individual with schizophrenia and retell it from memory. In my second study, I recruit participants from Prolific, and I ask them to watch a video and label the characters involved in the interaction they watched. I find that biases about individuals with schizophrenia shape the content participants remember and transmit, leading to narratives that become more stereotype-consistent over time. I also find that political partisanship has a strong relationship with how participants label the characters involved in the video of my second study. These findings contribute to the fields of cultural sociology, medical sociology, and political polarization. While varied in approach, both experiments show that culture, in a variety of forms, shapes not only how individuals interpret the world, but also how they interact with it.

Background: Despite increasing availability of preventative HPV vaccines and screening strategies, uptake of these effective measures in Kisumu, Kenya is limited by cultural and logistical barriers. Limited understanding and societal perceptions of HPV and cervical cancer are potential sources of stigma that could negatively impact screening behavior. By designing and implementing a stigma-responsive educational intervention, we sought to improve understanding and risk perception and increase the likelihood cervical cancer screening.

Methods: We carried out a study of a stigma responsive strategy to deliver HPV-based cervical cancer prevention services in Kisumu, Kenya. Focus group discussions (FGDs) explored experiences of HPV and cervical cancer screening, health messaging and potential stigma sources. Qualitative analysis of the FGDs informed the development of a stigma-responsive educational video. Four Kisumu County healthcare facilities were randomized to either watch the video or receive standard HPV and cervical cancer education, after which participants at both sites completed a survey to measure HPV- and cervical cancer stigma. Stigma scores were compared between control and intervention groups using linear regression.

Results: Thirty women participated in the focus group discussions. Drivers of stigma included concerns about confidentiality and disclosure of HPV results, fears of cancer or implications of a sexually transmitted infection diagnosis. Anticipated outcomes included illness or death, financial hardship or family abandonment. The FGDs findings informed development of the educational video. A total of 288 women, 109 in the intervention group, completed the stigma survey. Mean HPV and cervical cancer scores were found to be statistically lower in the intervention arm, with Dholuo language associated with higher stigma levels in both arms.

Conclusions: This multi-step study explored knowledge, attitudes and beliefs specific to HPV and cervical cancer health messaging in western Kenya in order to develop and test a stigma-responsive education strategy. The stigma-responsive video demonstrated a quantitative decrease in stigma survey response means for those who watched the video. The pre-pilot design will drive a larger pilot study to examine the effect of the educational video on HPV self-sampling.

Background: Cancer is grossly underreported and underdiagnosed in Africa, as only an estimated 57% of childhood cancers are diagnosed and survival rates for children with cancer are very low; an estimated 20% of children survive cancer in Africa. Several factors can lead to delays in treatment and discontinuing treatment such as lack of knowledge about cancer and negative beliefs or stigma about cancer. The research objective of this paper is to explore the types of stigmas faced by pediatric cancer patients and their families to inform interventions to reduce cancer stigma and increase survival rates of pediatric cancer patients in Tanzania.Methods: The study took place at Bugando Medical Centre (BMC) in Mwanza, Tanzania. The study sample included more than 300 patients who had completed treatment for pediatric cancer at Bugando Cancer Centre. This qualitative study was conducted using structured focus group discussions (FGD) and in-depth interviews (IDI) with patients and caregivers. Data was transcribed and translated into English and NVivo12 was used for qualitative data analysis and coding through an inductive and deductive approach. Results: The main themes of stigma found in both the FGDs and IDIs were severity of condition, avoidance, financial discrimination, beliefs about causes of cancer and stigma due to physical changes. These themes were found among all age groups and were experienced by both caregivers and patients. Conclusions: The results and data gathered from this study illustrate that cancer stigma is still an issue faced by pediatric cancer patients and their families. It also illustrates that, although some aspects of stigma have been described and addressed in the literature through adult stigma studies, there are aspects of stigma for pediatric cancer patients specifically that should be addressed. The data gathered here can be used to develop interventions targeted towards cancer stigma for pediatric populations, to reduce cancer stigma and increase survival rates of pediatric cancer patients in Tanzania.

Background: Worldwide, it is estimated that there are up to 150 million street children. Street children are an understudied, vulnerable population. While many studies have characterized street children’s physical health, few have addressed the circumstances and barriers to their utilization of health services.

Methods: A systematic literature review was conducted to understand the barriers and facilitators that street children face when accessing healthcare in low and middle income countries. Six databases were used to search for peer review literature and one database and Google Search engine were used to find grey literature (theses, dissertations, reports, etc.). There were no exclusions based on study design. Studies were eligible for inclusion if the study population included street children, the study location was a low and middle income country defined by the World Bank, AND whose subject pertained to healthcare.

In addition, a cross-sectional study was conducted between May 2015 and August 2015 with the goal of understanding knowledge, attitudes, and health seeking practices of street children residing in Battambang, Cambodia. Time location and purposive sampling were used to recruit community (control) and street children. Both boys and girls between the ages of 10 and 18 were recruited. Data was collected through a verbally administered survey. The knowledge, attitudes and health seeking practices of community and street children were compared to determine potential differences in healthcare utilization.

Results: Of the 2933 abstracts screened for inclusion in the systematic literature review, eleven articles met all the inclusion criteria and were found to be relevant. Cost and perceived stigma appeared to be the largest barriers street children faced when attempting to seek care. Street children preferred to receive care from a hospital. However, negative experiences and mistreatment by health providers deterred children from going there. Instead, street children would often self treat and/or purchase medicine from a pharmacy or drug vendor. Family and peer support were found to be important for facilitating treatment.

The survey found similar results to the systematic review. Forty one community and thirty four street children were included in the analysis. Both community and street children reported the hospital as their top choice for care. When asked if someone went with them to seek care, both community and street children reported that family members, usually mothers, accompanied them. Community and street children both reported perceived stigma. All children had good knowledge of preventative care.

Conclusions: While most current services lack the proper accommodations for street children, there is a great potential to adapt them to better address street children’s needs. Street children need health services that are sensitive to their situation. Subsidies in health service costs or provision of credit may be ways to reduce constraints street children face when deciding to seek healthcare. Health worker education and interventions to reduce stigma are needed to create a positive environment in which street children are admitted and treated for health concerns.

This dissertation examines racial socialization in Afro-Brazilian families in order to understand how phenotypically diverse families negotiate racial hierarchies and ideologies of white supremacy. As an inductive, qualitative project, this research is based on over fourteen months of ethnographic fieldwork in Salvador, Bahia, Brazil in fifteen poor and working-class Bahian families and 116 semi-structured interviews with family members and informants. Findings suggest that one of the most prominent features of racial socialization is the pervasive devaluation of black/African influences, which is conveyed through implicit and explicit messages as well as concrete practices (including rituals) that promote the stigmatization of negatively valued racialized physical features. The study reveals a pattern of unequal distribution of affection based on racial appearance (phenotype), which is evident in parent-child, sibling, extended family, and romantic relationships. Findings suggest that negative appraisals of racial phenotype may significantly compromise affective bonds in families and have social psychological consequences impacting self-esteem and sense of belonging, while also eliciting suicidal ideations and anxieties. These outcomes are most pronounced for Afro-Brazilian females. Racial socialization also conveys the "strategically ambiguous" logic of color and racial classification, uncritically exposes family members to racist messages, jokes, and stereotypical images of Afro-Brazilians, and encourages cultural participation that superficially valorizes Afro-Brazilian culture and fosters nationalism, rather than racial identity. In contrast to traditional findings of racial socialization in the U.S., messages valorizing racial heritage are rare and efforts to prepare family members for bias rely on universal terms. Families do employ counter-discourses and creative strategies of resistance; and so, racial socialization is characterized by practices that reflect both resistance and accommodation to racial hierarchies. I conclude that racial socialization in families is influenced by and sustains racialization processes that maintain the broader system of white supremacy. Contrary to how racial socialization has been framed as having a purely protective role in families, this study illustrates how it may disadvantage blacks vis-à-vis whites and uniquely stigmatizes the most "black-looking" family members vis-à-vis those who more closely approximate an idealized (whiter) somatic norm. Future studies should triangulate data on racial socialization from other regions of the Americas.

The social gradient of health is pervasive and unrelenting. Across nearly any layer of society – race, religion, economic standing, or others – the populations worst off in terms health are also the most socially disadvantaged. Over three studies, this dissertation examines some of the experiences that underlie the connection between social disadvantage and health, namely internalized perceptions of status, interpersonal interactions, and institutional actions. The first study examines the link between adolescents’ perceived social status and their mental health at a range of ages, identifying at what age mental health problems begin to track perceptions of status, as well as contextual factors that do (or do not) relate to perceptions of status. In the second study, data from a nationally representative survey in France are used to document rates of reporting discrimination within the healthcare setting by gender, immigrant status, race/ethnicity, and religion. Rates of foregoing medical care are also documented across the same groups, and the potential explanatory role of discrimination toward disparities in foregone care is then investigated. The third and final study looks at the role of institutional stigma, using state bans of Sharia law in the USA as an exemplary case of stigmatizing policies with minimal material consequences. National birth record data for the USA is used, and the variation in policy enactment over time and space is leveraged to examine birth outcomes for Muslim women who were pregnant at the time their state passed a ban. Findings reveal a decrease in the secondary sex ratio to targeted women, suggesting the stigmatizing policy acts as a population-level stressor with consequences for maternal health.

Background: Many health providers worldwide stigmatize people living with mental illness, creating a barrier to providing quality mental health services. Interventions aiming to reduce stigma during medical school have utilized education and contact-based methods to improve student attitudes towards mental illness. However, the effectiveness of these methods has never before been compared in medical schools in low-income countries. The aim of this study was to evaluate a video featuring a mental health service user with depression in a randomized controlled pilot trial among medical students in Nepal. Methods: In a three-armed randomized controlled pilot trial, participants were randomized to one of three conditions: a didactic video lecture based on the mental health Gap Action Programme Implementation Guide (mhGAP-IG) depression module, a service user testimonial video about living with depression, and a condition with no video presentation. Participants were 94 second and third year medical students in Nepal. All of the measures were collected post-intervention. The primary outcome was explicit attitudes measured on the Social Distance Scale (SDS). Additional outcomes were implicit attitudes on two Implicit Association Tests (IAT), diagnostic accuracy, treatment knowledge, and symptom knowledge. Results: Both the didactic lesson (SDS mean score, M = 33.32; standard deviation, SD = 9.57) and the service user videos (M= 30.13; SD= 9.16) had lower explicit stigma after the video presentations compared to the control (M= 39.10; SD= 11.14) (F2,91= 6.37, p= 0.003, R2= 0.12), but there was no difference between the two intervention conditions (F1,61= 1.55, p= 0.23, R2= 0.02). There were no significant differences on implicit associations (IAT d score), depression diagnosis, treatment knowledge, and symptom knowledge. Conclusions: Prerecorded videos (whether didactic or service user testimonials) are scalable learning tools that have potential to reduce explicit stigma among medical students in low resources settings. Additional research is necessary to explore the differences between both didactic education and service user testimonial interventions, as well as the potential outcomes when the videos are combined. A full scale randomized controlled trial will be conducted based on these findings.

Clinical Trials Registration: CTRN NCT03231761

Background: Even though a recent increase in HIV prevalence has been noticed in Sri Lanka, not many studies have been done there relating to HIV/AIDS. In particular, little is known about HIV-related stigma among healthcare workers, which has been identified as an obstacle to addressing the HIV epidemic. To examine this issue, this study first aimed to assess knowledge and attitudes of PHMs, the frontline community health workers in Sri Lanka. Second, the study examined the factors associated with their knowledge and attitudes. Lastly, the study examined the association of demographic information, knowledge, and attitudes with extra precautionary behaviors. Methods: Two hundred and ninety-one PHMs were recruited for this cross-sectional study. The study team visited each of the 20 Medical Officers of Health areas (MOH: administrative division) in the Galle District and surveyed PHMs during their monthly meetings. The study utilized two questionnaires to assess knowledge (16 items), attitudes and stigma (37 items). After assessing the PHMs knowledge and attitudes, the study explored the association of demographic information with knowledge and attitudes, and then examined how such individual factors, knowledge, and attitudes were associated with extra precautionary behaviors. Results: PHMs’ knowledge level was good (79.9% of answers were correct) but could be improved. Those more knowledgeable about HIV and with higher education demonstrated a more positive attitude towards PLWH. A more negative attitude was associated with having a stronger intention to engage in extra precautionary behaviors. Conclusions: As PHMs are community health workers whose attitude can potentially influence to the general public’s point of view, they need further HIV training to improve their knowledge so as to better educate the community. By reducing the PHMs misperceptions about HIV, they may develop a more positive attitude and thus help reduce stigma towards PLWH.

Background: Cancer stigma presents a critical barrier to care seeking, contributing to delayed presentation and poor cancer outcomes worldwide. The burden of cancer in Tanzania is on the rise, with cancer being the third-leading cause of death in the country. Despite rising incidence and poor outcomes of cancer, cancer-related stigma interventions have received low prioritization. There is a need for sound research that focuses on understanding attitudes driving stigma, its impact on care seeking and treatment adherence, and intervention models to reduce stigma. Methods: We administered three open-ended qualitative questions to 140 adults newly diagnosed with cancer in Moshi, Tanzania. The questions explored, (1) common attitudes toward people with cancer, (2) the perceived impact of cancer-related stigma, and (3) ideas for reducing stigma experienced by people with cancer. Patients were recruited during routine appointments at the Cancer Center at Kilimanjaro Christian Medical Center. Data were analyzed using a team-based, applied thematic approach and NVivo 12 software. Twenty percent of the responses were double coded to assess inter-coder agreement and exceeded a pre-established threshold of 80% agreement (84.9%). Results: Participants described stigma as a major challenge for treatment and for receiving support from their social networks. Perceptions of financial stress, misconceptions about cancer such as the belief that it is contagious, and fear of death were common attitudes driving cancer stigma. Participants feared that symptoms would prevent them from working and that the cost of cancer care would drive away loved ones. Stigma was not a ubiquitous response, as some participants reported increased care and social support from family members after a cancer diagnosis. Experiences of stigma contributed to feelings of shame, fear of burdening the family, reduced resources to access treatment, and disengagement from care. Common substitutes to medical therapies included religious interventions and traditional medicine, which were perceived as less expensive and less stigmatizing. Participants felt they would benefit from improved financial support and professional counseling, as well as education for families and communities to reduce stigmatizing attitudes and enhance social support. Conclusions: There is need for intervention studies focused on improving cancer literacy, community advocacy to reduce cancer stigma, and increasing support for people with cancer and their families. There is also a clear need for policy efforts to make cancer care more affordable and accessible to reduce the financial burden on patients and families.

Social interactions with civil society are an essential component of the refugee experience, actively shaping humanitarian aid as well as policies towards refugee needs (Barnes, 2011; Van der Leun & Bouter, 2015). However, material needs are frequently depicted as the main endeavor for refugee support. This overlooks the moral components of the refugee experience, through the need for dignity (del Soto, 2008), mental health resources (Silove et al., 2017) and a sense of security (Eby et al., 2011) which are essential support structures if refugees are to, even temporarily, live in the new communities they join. Notably, current research on existing systems emphasizes material refugee provisions with little focus on mental health (Weine, 2011) or the cultural implications of integration (Esses et al., 2017). This thesis explores refugees’ perceptions of integration in host countries with an emphasis on the lack of support structures beyond material humanitarian response in Egypt and Jordan as a secondary data analysis project. It is based on 108 qualitative life-story interviews with Iraqi refugees conducted by the Kenan Refugee Project of Duke University between 2012 and 2019 primarily in Cairo, Egypt and Amman, Jordan. Through this analysis, I determined a pressing need for a temporary, informal integration process with much needed social support and mental health resources beyond the current legal standards in place. I further argue that the multi-dimensional, multi-disciplinary nature of refugee needs are frequently overlooked and underestimated and that a new approach beyond materialprovisions at the global decision-making table is long overdue for the dignity, human rights and quality of life refugees deserve across the globe.

Background: Intimate partner violence is a preventable public health problem that disproportionality impacts women in Sub-Saharan Africa. Women with HIV have a higher burden due to HIV related stigma they may face. In Rwanda, women have higher incidences of HIV and intimate partner violence. This study aimed to estimate the prevalence of IPV among women living with HIV in Rwanda as well as measure the difference in psychological outcomes, demographic data, and HIV related outcomes. Methods: This study conducts a secondary data analysis of a Cross-sectional, descriptive observational study. 162 Rwandan women living with HIV were purposefully recruited to participate in the survey. The instrument measured demographic data, Intimate partner violence, depression, HIV related stigma, coping, self-esteem, and hope. Results: The prevalence of IPV in the sample was 26.61% with psychological being the most prevalent followed by physical then sexual. Demographic data had no statistical significance with the prevalence of IPV. Women with HIV who experienced IPV had higher HIV stigma, lower coping self-efficacy, lower self-esteem, and less hope levels. Conclusions: Women who experience IPV have worse HIV psychological outcomes which could lead to decreased overall health outcomes. Further studies are needed to look into the correlation between the two as well as interventions addressing IPV prevention and awareness.

Weight bias internalization is considered a chronic discriminatory stressor and a threat to health. Weight bias internalization has known associations with health-depleting behaviors (i.e., disordered eating, social isolation) and avoidance of health-promoting behaviors (i.e., physical activity, adherence to healthcare guidelines). Despite the numerous deleterious health effects of weight bias internalization, relatively few efficacious interventions have been identified for this critical treatment target. Self-compassion training presents itself as a potential intervention, though has not been rigorously tested in those with elevated internalized weight bias. Ruby was a two-arm randomized control designed to reduce internalized weight bias. Ruby tested the efficacy of a 4-week digitally-delivered self-compassion intervention compared to wait list control. Participants in the intervention group received daily text messages which included psychoeducation videos, writing prompts, and guided mindfulness audio files to facilitate daily mindful self-compassion practices ranging from 4-21 minutes per day. The main outcome of this trial was the 4-week reduction in weight bias internalization as measured by the Weight Bias Internalization Scale, compared to wait list control. Trial outcomes were analyzed using linear mixed models and one-way analysis of covariance models using an intent-to-treat framework. Ruby participants were 121 adults with elevated internalized weight bias (i.e., WBIS score > 4.0) and a body mass index over 30 kg/m2. Participants in the intervention demonstrated greater reductions in weight bias internalization compared to the wait list control (Net difference: -0.84, CI: -1.21 to -0.48, p < .0001). Participants in the intervention demonstrated similar reductions in secondary outcomes, including weight self-stigma, weight-related experiential avoidance, and fear of self-compassion (p’s < .05). Additionally, they reported increases in self-compassion, mindfulness, body appreciation, intuitive eating, and physical activity. Mediation analyses suggest that reductions in weight bias internalization are likely partially driven by increases in self-compassion. Ruby was the first digital standalone self-compassion based intervention targeting weight bias internalization. Results suggest that a brief mindful self-compassion intervention can meaningfully reduce internalized weight bias over 4 weeks. Additionally, a mindful self-compassion intervention can reduce several other secondary outcomes related to internalized weight bias. Due to its standalone digital delivery, Ruby may be a highly-scalable treatment for internalized weight bias that can be delivered on its own or combined with other treatments. Ruby is poised to expand a burgeoning body of literature related to psychological intervention for internalized weight bias.

My dissertation is a project of practical theology that starts with the problem of homelessnesss. It seeks to better understand the lived faith of homeless persons by listening to the voices of the extreme poor. It asserts that one common feature of homelessness is loss, particularly the loss of being accepted as fully human. This plays out in stigmatization and shame, whereby homeless persons are treated and can come to perceive themselves as transgressors matter out of place. Using an ethnographic method and a situational analysis of social worlds, I participated in and observed three homeless social worlds at a downtown church in Nashville: a midweek worship service, a street paper, and a weekly support group. I also used a photo-elicitation process to discover how the homeless found sacred spaces and held onto sacred things as they lived on the streets. Because it is important to understand the larger historic and socioeconomic forces and material realities impacting the lived faith of the homeless, I also describe the making of the places of Nashville, the church, and the three social worlds. Besides participation-observation fieldnotes, my data primarily came from interviews with 40 homeless and formerly homeless persons as well as the leaders of each social world. I conclude with a theological reading and evaluation of the church's homeless social worlds according to my own theological normative claims of the homeless person being beloved and nourishing a sense of his or her agency. Using Rowan Williams and Sandra Schneiders, I work toward an adequate definition of spirituality that allows for attention to the radically different lives of homeless persons who typically remain invisible to most Christians and academic theology, and I make a case for spirituality as a viable analytical concept in practical theology and as a discipline in theological education.