Stigma assessment: Scales review

JCTEI JOURNAL OF CLINICAL TRIALS AND EXPERIMENTAL INVESTIGATIONS 7 Year: 2025 Volume: 4 Issue: 1 10.5281/ zenodo.15571012 Stigma assessment: Scales review REVIEW ARTICLE María Teófila Vicente-Herrero¹, Miguel Ruiz-Flores Bistuer², María Victoria Ramírez Iñiguez de la Torre³, Carmen Muñoz Ruipérez⁴, Ángel Arturo López González⁵ 1. ADEMA Health Group, University Institute for Health Sciences Research (IUNICS), Palma, Balearic Islands, Spain. 2. Mental Health Unit, Ibsalut, Ibiza (Balearic Islands), Spain. 3. Specialist in Occupational Medicine, Occupational Health Service, Correos Group, Albacete, Spain. 4. Occupational Medicine and Occupational Risk Prevention Service, 12 de Octubre University Hospital, Madrid, Spain. 5. ADEMA Health Group, University Institute for Health Sciences Research (IUNICS), Palma, Balearic Islands, Spain. Abstract Objective: The assessment of stigma is a multifaceted process requiring a comprehensive understanding of stigma itself, quantification of its degree, evaluation of changes over time, and assessment of the effectiveness of interventions aimed at reducing or preventing it. This study aims to review some of the most widely used scales in health-related stigma assessment and to compare them in terms of their specific characteristics, strengths, and limitations. Materials and methods: In January 2025, a review was conducted using the PubMed database to analyze publications addressing the assessment of stigma through scales or questionnaires. Specific descriptors were employed, focusing on mental illnesses, infectious diseases, overweight and obesity, and sexual and gender minorities. Comparative reviews and studies detailing the application and performance of these scales were included in the analysis. Results: The review identified and compared 20 scales for assessing mental health stigma, 12 scales for stigma related to infectious diseases and symptoms, 17 scales for weight stigma, and 17 scales for stigma affecting sexual and gender minorities. Conclusion: Stigma limits the life opportunities of individuals experiencing discrimination due to illness or personal and social circumstances. Most stigma assessment scales and questionnaires lack specificity, methodological rigor, and clear definitions tailored to the particular stigma being evaluated. Future research should prioritize the development of robust conceptual frameworks, enhance methodological validity, and promote earlystage interventions to mitigate harm caused by stigma. Cite as: Vicente-Herrero MT, Bistuer MRF, Iñiguez de la Torre MVR, et al. Stigma assessment: Scales review. J Clin Trials Exp Investig. 2025;4(1):7-19. Correspondence Mª Teófila Vicente-Herrero, ADEMA Health Group, University Institute for Health Sciences Research (IUNICS), Palma, Balearic Islands, Spain. e-mail vicenteherr[email protected] Received: 21 January 2025 Revised: 10 February 2025 Accepted: 16 February 2025 Published: 19 March 2025 Keywords @Stigma assessment @Mental illness @Infectious diseases @Obesity @Gender @Sexual minorities ORCID ID of the author(s): MTVH: 0000-0002-0796-9194 MRFB: 0009-0008-2141-222X MVRIT: 0000-0002-7772-5689 CMR: 0000-0003-3976-1686 AALG: 0000-0002-7439-8117 2822-5090 /© 2025 Journal of Clinical Trials and Experimental Investigations. Published by Unico's Medicine. This is an openaccess article under the terms of the CC BY license. (https://creativecommons.org/licenses/by/4.0/) 8 JCTEI Introduction Stigma related to health is defined as a social process or personal experience characterized by exclusion, rejection, blame, or devaluation. This arises from the experience or reasonable anticipation of adverse social judgment against a person or group identified with a particular health issue (1). Factors contributing to stigma may vary based on personal, social, and cultural contexts. The health-related consequences can affect various areas of life for the individual and their surroundings (2). Stigma is a global health problem, complex in nature, and challenging to measure (3). It exacerbates the burden of a wide range of health conditions. Tools have been developed to measure stigma, focusing on various health conditions, often specific to particular diseases. The availability of measurement instruments is essential for understanding the stigma process, quantifying its severity, tracking changes over time, and assessing the effectiveness of interventions aimed at reducing or preventing it (4,5). This study aims to review some of the most commonly used scales for assessing health-related stigma and provide a comparative analysis of their specific characteristics, strengths, and limitations. Materials and methods A literature review was conducted in January 2025 using the PubMed database to analyze publications addressing the assessment of stigma through scales or questionnaires across various health conditions. Keywords used included: • Mental health conditions: "stigma and mental health," "mental disease." • Infectious diseases: "stigma and COVID-19," "Ebola virus," "HIV/AIDS," "other retroviruses," "communicable diseases," "disease outbreaks," "epidemics," "prejudice," "social discrimination," "social marginalization," "social stigma." • Obesity and overweight: "stigma and weight gain," "obesity," "overweight," "measurement," "psychometrics." • Sexual and gender minorities: "stigma and sexual and gender minorities," "measurement instruments," "psychometric properties." In the second phase of the review, comparative analyses for different scales and questionnaires were examined for each construct to unify evaluation criteria. Table 1: Scales for mental health stigma assessment SELF-APPLIED SCALES FOR MEASURING PUBLIC MENTAL HEALTH STIGMA Disease Scale Description Nº items Reported and Intended Behaviour Scale (6) RIBS Past behavior and future intention to interact with people with mental health problems. 8 Mental Health Knowledge Schedule (7) MAKS General knowledge about mental health and recognition of mental disorders. 16 Attitudes to Mental Illness Questionnaire (8) AMIQ Assesses the impact of media or educational interventions on the public's perception of mental health 5 Community Attitudes Toward the Mentally Illness (9) CAMI Community attitudes toward people with mental disorders Validated in Spanish (10) 40 Mental Illness Stigma Scale (11) MISS Assesses stereotypes and attitudes toward mental illness 28 The Attribution Questionnaire (12) AQ-27 Assesses stigmatizing beliefs and attitudes about people with mental illnesses Validated in Spanish (13) 27 9 JCTEI 9 JCTEI Social Distance Scale (14) SDS Measures a person's willingness to interact with someone with mental illness in different social contexts 7 Perceived DevaluationDiscrimination Scale (15) PDD Measures a person's perception of social discrimination toward individuals with mental illnesses 12 Peer Mental Health Stigmatization Scale (16) PMHSS-24 Measures stigmatizing attitudes towards mental health among peers Validated in Spanish (17) SELF-APPLIED SCALES TO MEASURE MENTAL HEALTH SELF-STIGMA Internalized Stigma of Mental Illness Scale (18) ISMI-29 Aimed at people with mental illness, it measures the degree to which they have internalized stigma. Validated in Spanish Stigma Internalized Stigma of Mental Illness (EIEM) (19) 29 Stigma Scale for Receiving Psychological Help (20) SSRPH Measures the stigma associated with seeking psychological help. Assesses perceived barriers to accessing treatment due to concerns about the opinion of others. 5 Self-Stigma of Mental Illness Scale (21) SSMIS Aimed at people with mental illness that measures the extent to which they adopt negative beliefs about themselves based on social stereotypes 40 Stigma Consciousness Questionnaire (22) SCQ Measures a person's awareness of social stigma and the impact they believe it has on their life 10 Discrimination and Stigma Scale (23) DISC-12 Measures discrimination and stigma experienced by people with mental illness in different settings, such as family, work, health services, and society in general 12 Escala de estigma internalizado de King et al (24) ISS Measures the stigma perceived by people with mental illnesses Validated in Spanish (25) 28 Self-Stigma in Relatives of people with Mental Illness scale (26) SSRMI Aimed at family members of people with mental illness, it measures the degree of self-stigma. Validated in Spanish (AFPEM) (27) 30 City Mental Illness Stigma Scale (28) City MISS Stigma in women with mental illness in the perinatal period. 30 SELF-APPLIED SCALES FOR MEASURING STIGMA IN THE MENTAL HEALTH WORKPLACE Opening Minds Scale for Workplace Attitudes (29) OMSWA Assesses attitudes toward mental health in the workplace. 15 Opening Minds Scale for Health Care Providers (30) OMSHC Specifically designed to assess stigma toward mental illness in health care professionals 20 Workplace Mental Illness Stigma Scale (31) w-MISS Specifically designed to assess stigma toward mental illness in the work setting 40 10 JCTEI Table 2: Scales for assessment of stigma in infectious diseases Disease Scale Description Nº items INFECTIOUS DISEASES: COVID 19-SARS-COV 2 COVID-19 Stigma Scale (32) It is clear, concise and easy to apply. It measures the stigma experiences of those who had recovered from COVID-19. It represents the self-feeling (items 1 to 6) and the external aspect that appears in the treatment of others (items 7 to 14). 14 Community COVID-19 Stigma (33) Measures community attitudes toward those diagnosed/ suspected of COVID-19. 6 COVID-19 (CSSHCWs) (34) The scale consists of three domains: personal stigma, concerns about disclosure and others, and family stigma. 18 CEDISC, 519 (35) Assesses experienced discrimination 12 COINS, 155 (35) Assesses internalized stigma among persons who were infected with SARS-CoV-2 or who survived Covid-19. 13 Pandemic OxfordCOVID-19 (OPAS-C) (36) Addresses mental health measures and public health-relevant responses to Covid-19: stress, fear, loneliness, sense of community, belief that the pandemic is a hoax or exaggerated, use of and attitude toward non-pharmaceutical interventions, and vaccine hesitancy, 20 Long Covid Stigma Scale (LCSS) (37) It quantifies the burden of prolonged COVID stigma in three domains: enacted stigma (overt experiences of discrimination), internalized stigma (internalization of negative associations with prolonged Covid and acceptance of them as self-applicable), and anticipated stigma (expectation of bias/bad treatment by others). 13 INFECTIOUS DISEASES: HIV VIH de Berger (HSS) (38) It is being used to identify people at risk for poor psychological outcomes and to inform the development and evaluation of interventions to reduce HIV-related stigma. Its validity is limited, in African, Asian, Oceanic and South American settings. 30 VIH de Berger (HSS) (39) It consists of four factors: personalized stigma (seven items), disclosure concerns (three items), negative self-image (four items), and concerns about public attitudes toward people with HIV (four items). 18 HIV Stigma Framework (40) Focuses on individual rather than structural processes and on understanding how stigma affects outcomes for both HIVinfected and HIV-uninfected individuals. INFECTIOUS DISEASES: EBOLA (41) The Ebola-related stigma questionnaire was derived from Berger’s HIV stigma scale Assesses stigma associated with Ebola survivors and change over time in perceived stigma. Allows categorization of the type of stigma of survivors of the Ebola epidemic in West Africa. 13 PERSISTENT SOMATIC SYMPTOMS (PSS) (42) PSSS-HCP, available in both 19-item and 13-item versions Explores stigmatization by health professionals towards people with persistent somatic symptoms and allows measurement of important aspects of stigma, a basis for evaluation of stigma reduction interventions. 19, 13 11 JCTEI Table 3: Sexual and gender minority multifaceted stigma rating scales. Full name and acronym Description Nº ITEMS Subjective Scale of Stigma and Discrimination (SISD) (43) Assesses the following factors: Experiences of stigma and discrimination [5 items], Disadvantages in the presence of authorities [3 items], Discrimination at work [6 items], Expression of sexual identity [3 items], Institutional exclusion and denial of rights [3 items], and Religious discrimination [3 items]. 23 items Stigma and trust in healthcare providers (STHP) (44) Assesses the following factors: Manifested stigma [10 items], Mistrust of health care providers [7 items], Internalized stigma [5 items]. 22 Stigma Consciousness Questionnaire (SCQ) (45) Assesses stigma of homosexuals through Beliefs about stigma and experiences about stigma. 8 Minority Stress Scale (MSS) (46) Assesses the following factors: Structural stigma [3 items], Manifested stigma [3 items], Expectations of discrimination [12 items], Expectations of discrimination from family members [3 items], Concealment of sexual orientation [7 items], Internalized homophobia toward others [6 items], Internalized homophobia toward self [6 items], Awareness of stigma [3 items]. 43 Sexual Stigma Scale (SSS) (47) Assesses perceived stigma (5 items) and manifested stigma (7 items) in women identifying as lesbian, bisexual or queer 12 Gender Non-affirmation from Cisgender Male Partners Measure (GNCMP) (48) Assesses the frequency of gender non-affirmation and stigma-related experiences in the context of a sexual encounter with a cisgender man in the past 6 months 4 Malaysian Version of Homosexuality Attitude Scale (MVHAS) (49) Assesses Moral perception (7 items), Intrapersonal relationship (5 items), Stigmatization (5 items), Social distancing (4 items). 21 Sexual Orientation Concealment Scale (SOCS) (50) Assesses concealment of sexual orientation 6 Internalized Homophobia (IH) (51) Assesses Desire to be heterosexual [8 items], Fear of coming out [4 items] and Fear of stereotypical perception [3 items]. 15 Transgender Identity Survey (TIS) (52) Assesses Pride (8 items), Pass (7 items), Alienation (3 items) and Shame (8 items) in transgender people. 26 Measure of Internalized Sexual Stigma for Lesbians and Gay Men (MISS-LG) (53) Assesses Identity [5 items], Social Discomfort [7 items] and Sexuality [5 items]. 17 Internalized Homophobia Scale for Vietnamese Sexual Minority Women (IHVN-W) (54) Assesses: Self-stigma I: Not normal/healthy [4 items]. Self-stigma II: Self-reproach and desire for same-sex sexuality to disappear [4 items], and Sexual prejudice [3 items]. 11 Intersectional Stigma (IS) (55) Assesses Enacted Stigma [24 items] and Anticipated Stigma [20 items] in relation to Intersectional Attributes: race-sex behavior, race-HIV, sexual-HIV behavior, and racial-sexual-HIV behavior. 44 Integrated Race and Sexuality Scale (IRSS) (56) Assesses Emotionality/restricted affect [17 items], Internalized Bi/homophobia [10 items], Success/power/competence [13 items], and) Integrated race and sexuality [7 items]. 47 Perceived Stigma (PS) (57) Assesses perceived stigma in young men who have sex with men. 7 Sexuality Questionnaire (SQ) (58) Assesses concern about sexuality [12 items] (2) same-sex sexual desire [11 items], desire for other sexual requirements [5 items], sexual immorality [4 items], judgment avoidance [5 items], no need confrontation/shame [3 items]. 40 Gay Community Stress Scale (GCSS) (59) Assesses Sex [6 items], Status [5 items], Competence [6 items], Exclusion [8 items], External [7 items]. 32 12 JCTEI Table 4: Weight-related stigma rating scales. Full name and acronym Description Nº ITEMS The weight self-stigma questionnaire (WSSQ) (60) Self-evaluation and fear of directly experiencing stigma due to weight status. 12 Weight-focused forms of selfCriticizing/ self-attacking and self-reassuring scale (WFSCRS) (61) It assesses how individuals relate to themselves when they experience failures, limitations or threats to their social status. Three subscales: Inadequate Self (9 items), Hated Self (5 items), Calm Self (8 items). 22 Weight bias internalization scale (WBIS) (62) Assesses beliefs that stereotypes and negative statements about overweight/obesity apply to oneself. 11 Weight based rejection sensitivity (WBRS) (63) Assesses anticipated rejection around weight. 16 Weight-and body-related shame and guilt scale (WEB-SG) (64) Consists of two subscales: shame subscale (6 items), guilt subscale (6 items). 12 Stigmatizing situations inventory (SSI) (65) Consists of two subscales: Stigmatizing situations (50 items) and Coping responses (99 items). 149 Quality of life for obesity surgery questionnaire (QOLOS) (66) To assess the impact of excess skin after weight loss on appearance and health-related quality of life. Two subscales: Section 1: 36 items relevant for both preoperative and postoperative patients), Section 2 for postoperative patients only (20 items). 36, 20 Physical appearance related teasing scale (PARTS) (67) Consists of two subscales: weight/size teasing (12 items), general appearance teasing (6 items). 18 Perception of teasing scale (POTS) (68) Consists of two subscales: weight-related teasing (6 items), competence teasing (5 items). 11 Perceived weight-based stigmatization scale-Urdu (PWSS-U) (69) Assesses perceived weight-related stigma 43 Perceived weight-based stigmatization scale (PWSS) (70) Assesses perceptions of potentially negative attitudes and impressions based on weight from family, friends, and peers 16 Perceived weight discrimination (PWD) (71) Assesses perceived quality of life in relation to weight. 9 Obesity and weight-loss qualityof-life questionnaire (OWLQOL) (72) Consists of two subscales: Obesity and Weight Loss Quality of Life Questionnaire (41 items), Weight Related Symptom Measure (20 items). 61 Impact of weight on quality of life-lite (IWQOL-lite) (73) Assesses perceived quality of life in relation to weight 5 Impact of weight on quality of life (IWQOL) (74) Assesses perceived quality of life in relation to weight 11 Healthcare questionnaire (HCQ) (75) Focuses on treatment-seeking (seeking treatment related to weight and eating disorders) 10 Experience of weight-based discrimination (EWD) (76) Assesses experience of weight discrimination 6 13 JCTEI Results • Mental health stigma: A comparative analysis was conducted for 20 scales, including 9 scales for assessing public stigma, 8 for self-stigma, and 3 for workplace stigma (Table 1). • Stigma in infectious diseases and symptoms: Comparisons were made for 12 scales, including 7 for COVID-SARS-CoV-2, 3 for HIV, 1 for Ebola, and 1 for persistent somatic symptoms (Table 2). • Stigma in sexual and gender minorities: A comparative analysis was conducted for 17 scales assessing stigma in this group (Table 3). • Stigma related to overweight and obesity: A comparison was made for 17 scales designed to assess stigma in this context (Table 4). Discussion Stigma is a social determinant of health that impacts morbidity, mortality, and health disparities. Consequently, it should be considered alongside clinical and epidemiological management in studies addressing the social determinants of population health (77). Stigmatization has proven to be a barrier to seeking medical care, adhering to treatments, and managing a variety of health conditions globally. To halt this process and mitigate its harmful consequences, it is essential to establish a theoretical framework guiding the development of interventions, measurement tools, research, and policy measures. A global and crossdisciplinary framework applicable to various health conditions—as well as stigma related to race, gender, sexual orientation, social class, and occupation—has been proposed (78). Measurement tools are critical for understanding the stigma process, assessing its magnitude in specific contexts, monitoring changes over time, and evaluating the efficacy of stigma-reduction interventions. A wide range of tools has been developed to measure different facets of health-related stigma. However, despite recent advancements, measuring healthrelated stigma remains complex, with persistent challenges and knowledge gaps. Researchers have sought to better understand these challenges and to establish priorities for stigma-related research, focusing on existing measurement approaches and future research needs (79). Questionnaires are among the tools used to measure stigma. In practice, ultra-brief versions (e.g., SSOSH-3) and revised versions (e.g., SSOSH-7) of the Self-Stigma of Seeking Help Scale have been employed (80). However, to significantly reduce health-related stigma and discrimination, single-level approaches targeting isolated groups are insufficient. A patient-centered approach is required, starting with intrapersonal interventions to empower affected individuals. These efforts can support the development and implementation of stigma-reduction programs across broader societal levels (81). The consequences of stigma are remarkably consistent across different health conditions, cultures, and public health programs. Numerous instruments have been designed to assess the intensity and dimensions of stigma, yet many are condition specific. This underscores the need for the development of generic instruments for evaluating health-related stigma. Such instruments must be validated, refined, or adapted to ensure versatility and applicability in diverse contexts (82). Chronic health conditions are often accompanied by stigma, contributing to a hidden burden of disease. A practical definition of health-related stigma has been proposed to facilitate the implementation of intervention strategies. These strategies should focus on controlling or treating specific health problems through evidence-based social and health policies, counteracting stigmatization, and supporting stigmatized individuals by reducing their vulnerability and strengthening their resilience (83). Research on stigma continues to present new developments and challenges for investigators (84). Stigma is a critical factor in mental health and psychiatric conditions. For individuals with mental illness, internalized stigma (self-stigma) manifests as a subjective perception of devaluation, marginalization, secrecy, shame, and withdrawal. This leads to adverse effects, such as psychological distress, demoralization, hopelessness, reduced self-esteem and self-efficacy, impaired social adaptation, unemployment, income loss, lower adherence to psychiatric medications, and limited social support. Consequently, stigma exacerbates individual distress levels. Internalized stigma and its iatrogenic effects during 14 JCTEI psychotherapeutic treatment can significantly reduce mental health service utilization, lower quality of life, and increase avoidant coping. Overall, it is considered a risk factor for poorer mental health outcomes. The systematic measurement of internalized stigma provides clinicians and researchers with a viable target for general psychotherapeutic interventions. Among the many scales and questionnaires available, the Internalized Stigma of Mental Illness (ISMI) scale is widely used and compares favorably with other measures addressing similar themes. This 29-item scale assesses self-stigma among individuals with psychiatric disorders. A 2014 review by Jennifer E. Boyd et al identified 55 known versions of the ISMI scale, including 47 available translations in languages such as Arabic, Armenian, Bengali, Chinese (mainland, Taiwan, Hong Kong), Dutch, English (U.S., South Africa), Farsi, French, German, Hindi, Japanese, Korean, Portuguese, Spanish (Spain), Swahili, and Urdu, among others (85). Adaptations also exist for specific conditions such as depression, schizophrenia, substance abuse, and eating disorders. The review concluded that the ISMI scale is reliable and valid across a wide range of settings, disorders, and cultures. Generally, higher levels of internalized stigma are associated with greater depression severity, more pronounced psychiatric symptoms, lower selfesteem, and fewer recovery options. However, the authors noted the need for further research to explore the cultural impact on internalized stigma and identify ways to reduce it. Stigma in infectious diseases Stigma related to infectious diseases has been extensively studied, particularly for HIV, Ebola, and COVID-19, all of which have been associated with outbreaks. The COVID-19 pandemic exemplified the creation of a social stigma and discrimination environment, targeting individuals infected or at risk of infection. These issues were exacerbated by infection control measures such as quarantine, isolation, and confinement. During the pandemic, studies were conducted to develop and validate scales for assessing COVID-19-related stigma, focusing on their validity and reliability. In the absence of robust stigma-specific scales for infectious diseases, it becomes challenging to identify where interventions are most needed and evaluate their effectiveness during outbreaks. A 2023 review by Amy Paterson et al examined stigma scales developed during infectious disease outbreaks (86). This comprehensive analysis of 43 scales assessed their psychometric properties, transferability, and limitations. Of these scales, 98% were outbreakspecific, and 88% were used only once. Despite covering themes such as public stigma, occupational stigma, structural stigma, and self-stigma, the review highlighted significant gaps in validation and applicability across contexts. The study concluded that stigma during outbreaks is often measured incompletely and unreliably, making it difficult to compare findings across outbreaks. Furthermore, the development of these scales is typically too slow to provide actionable insights at the beginning of an outbreak when they are most needed. A transferable, rigorous stigma assessment scale is urgently required to guide stigma responses during infectious disease outbreaks. Stigma related to obesity and overweight Weight-related stigma is recognized as a risk factor for eating disorders, psychological stress, and reduced healthcare utilization. A 2021 review by Stephenie Papadopoulos et al analyzed 18 self-report measures of weight-related stigma. These measures captured diverse aspects, including perceived discrimination, healthcare experiences, quality of life, and internalized weight bias (87). However, none provided comprehensive psychometric information or met methodological quality standards. The authors emphasized the urgent need to develop measures reflecting accepted conceptualizations of weight stigma. These tools should involve input from both experts and affected populations to ensure relevance, comprehensibility, and comprehensiveness. Stigma in sexual and gender minorities Stigma negatively impacts the health of sexual and gender minorities. A 2024 review by Abhishek 15 JCTEI Aggarwal et al evaluated 17 instruments based on their psychometric properties, including content validity, reliability, and responsiveness (88). Most tools focused on stigma among gay men, with fewer addressing women or intersectional stigma. The authors concluded that future research should prioritize developing intersectional stigma instruments that consider multiple social identities. Additionally, existing instruments require further psychometric testing, particularly in cross-cultural validity and adaptability for diverse LGBTQIA+ populations. Conflict of interest The authors report no conflict of interest. Funding source No funding was required. Ethical Approval This article does not contain any studies with human participants or animals performed by any of the authors. This is a review article and no need for ethical approval. Informed consent This is a review article and no need for informed consents. Acknowledgment: None Peer-review Externally. Evaluated by independent reviewers working in at least two different institutions appointed by the field editor. Data availability The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Contributions Research concept and design: MTVH, MRFB, MVRIT Data analysis and interpretation: MTVH, MRFB, CMR, AALG Collection and/or assembly of data: MTVH, CMR, AALG Writing the article: MTVH, MRFB, MVRIT, CMR, AALG Critical revision of the article: MRFB, MVRIT, CMR, AALG Final approval of the article: MTVH, MRFB, MVRIT, CMR, AALG All authors read and approved the final version of the manuscript. References 1. Weiss MG, Ramakrishna J. Stigma interventions and research for international health. Lancet. 2006;367(9509):536–8. 2. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27(1):363–85. 3. Stevelink SAM, Wu I, Voorend C, Van Brakel W. The psychometric assessment of internalized stigma instruments: A systematic review. Stigma Res Action. 2012;2(2):100-18. 4. Heijnders ML, Meij SVD. 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