In my various readings this past week, I was introduced to an idea that was new to me, although linked to ones with which I am familiar. It clearly has implications for oncology nursing and, therefore, is an idea I thought you might be interested in learning about.
The idea I learned about emerged during the preparation for a presentation I was doing on stigma in cancer care. I am sure you are all familiar with the notion of stigma that occurs when a person possesses, or is believed to possess, an attribute or characteristic that conveys a social identity that is devalued in a particular social context. In health-related situations, the exclusion, blame, or devaluation of another person arises from an individual having a particular health problem. It arises in situations when the individual is thought to be responsible for the health condition, there is disfigurement or disability, or the individual’s behaviour results in lack of control or disrupts social interactions. Stigma is heightened if a disease is seen as controllable.
Stigma frequently exists regarding lung cancer, but can also arise with cervical cancer. Individuals who experience stigma may also experience depression, increased symptom burden, decreased quality of life, poor provider-patient communication, and decreased adherence to treatment. Lower screening uptake, avoidance of healthcare and decreased help-seeking are all associated with stigmatization as individuals fear being blamed, censured, or labelled. (See references below.)
The new concept for me was one called ‘stacked stigma’ or ‘corrosive disadvantage’. This concept refers to the situation when one disadvantage leads to another or when an individual falls into two or more groupings that could, on their own, result in negative consequences from stigmatization. For example, stigmatization could arise from being grouped in any one of these groups: elderly, overweight, low education, low income, sexual minority, or new immigrant. Having a health condition and belonging to more than one of these groups could result in the disadvantages having a cumulative effect.
Stigma operates at both explicit and implicit levels. The explicit level is much easier to observe and identify, but it sometimes takes a concerted effort to bring the implicit level thinking into conscious awareness. Without bringing implicit ideas into conscious awareness, our behaviours could easily be based on our hidden thinking and result in patients and family members feeling stigmatized.
Learning about stacked stigma made me start thinking about oncology nursing practice and how this idea might influence how we interact with patients and family members. How do we phrase the question about smoking to a lung cancer patient? How do we inquire about sexual partners for women with cervical cancer? Are there some individuals we do not look in the eye or talk as much with as we would others? Are there some individuals we do not take the time to teach in as much detail, offer and discuss as many options, or engage in shared decision-making?
And what are the reasons driving such behaviour? Could our behaviours be happening because we have assigned attributes or characteristics to patients, either explicitly or implicitly, which we see as negative?
I believe it is important for us to think about our role and any behaviours that could be contributing to, or perpetuating, ‘stacked stigma’. I have added some references below to get you started! I encourage you to take a few minutes from your busy day to look up these articles, read them, and think about how your patients could benefit from what you learn.