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Assessing stigma in low- and middle-income countries: A systematic review of scales used with children and adolescents

Research output: Contribution to journalReview articlepeer-review

Luana Gavan, Kim Hartog, Gabriela V. Koppenol-Gonzalez, Petra C. Gronholm, Allard R. Feddes, Brandon A. Kohrt, Mark J.D. Jordans, Ruth M.H. Peters

Original languageEnglish
Article number115121
JournalSocial Science and Medicine
Early online date14 Jul 2022
Accepted/In press7 Jun 2022
E-pub ahead of print14 Jul 2022
PublishedAug 2022

Bibliographical note

Funding Information: We would like to thank Dr. Wim van Brakel, Medical Director at NLR International, for his support in cross-cultural equivalence rating. We thank the Dutch Relief Alliance (DRA), which is funded by the Dutch Ministry of Foreign Affairs , for financial support to author Kim Hartog. B.A. Kohrt and M. J. D. Jordans are supported by the U.S. National Institute of Mental Health (Grant no. R01MH120649 ). B.A. Kohrt and M. J. D. Jordans are supported by the U.S. National Institute of Mental Health (Grant no. R01MH120649 ). Publisher Copyright: © 2022 The Author(s)


King's Authors


Introduction: Stigmatization contributes to health inequalities, impacting the wellbeing of children and adolescents negatively. Addressing stigmatization requires adequate measurement. Our systematic review synthesizes the content of scales used with children and adolescents in low- and middle-income countries (LMICs) across stigmas, and examines their comparability and level of cultural adaptation. Methods: Ten databases were systematically searched combining three sets of search terms: (i) stigma, (ii) scales, and (iii) LMICs. Studies conducted in LMICs, with a sample with mean age below 18 and reporting a minimum of one stigma scale, were eligible. We allocated scale items to four frameworks: (i) dimensions, or drivers of stigmatization; (ii) target variants, or types of stigmatization; (iii) socio-ecological levels, and (iv) cross-cultural equivalence, or scale adaptation to context/population. Based on percentages, we compared scale content per age cohort, stigma status, region, and stigma category. Results: Out of 14,348 records, we included 93 articles (112 scales). Most studies focused on adolescents (12–18 years). Twelve scales were used more than once, seven were used across regions, and four were employed for multiple stigmas. Physical health stigma, and HIV/AIDS-related stigma in particular, was measured most; mental health and multiple/generic stigmas least. Physical and mental health scales were generally more comprehensive, i.e., measuring more stigma facets. In general, scales consistently measured two of the 21 included stigma facets, namely the disruptiveness dimension and the community level. Cross-cultural equivalence was moderate; conceptual and measurement equivalence were high. Discussion: Although scales were largely comparable in how they measure stigma, they failed to reflect the complexity of the stigmatization process and fell short of existing stigma frameworks and qualitative research. Stigma research with children should work towards cross-culturally validated stigma scale sets which incorporate more facets of existing stigma frameworks, thus facilitating comparability across cultural contexts and informing intervention development and evaluation.

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