HIV/AIDS: Stigma and discrimination

Stigma and discrimination face by people living with HIV/AIDS
It has been defined by Roura et al., (2009) that the stigma associated with a precise kind of relationship between the behvaiours, perceptions and stereotypes is concerned with a deep sense of social deprivation. Despite the fact, that the concept of stigma is around 40 years old, it has been much researched on and is widely used to draw implications both in social and cultural contexts. All societies have imparted convictions and implications which help them translate encounters and conduct. Implanted inside that framework are the “regulations” based on which is to be demonized and who is definitely not. Despite the fact that these “guidelines” may contrast from society to society, shame is for the most part considered an “adverse, moral or judgemental meaning of an individual or social circumstance, regularly joined with disparaging, disrespect, fault, and attribution of obligation regarding the condition”. Disgrace is not just connected to persons with undesirable physical properties. A great many people are acutely mindful that persons with undesirable characteristics, whether physical, mental or passionate, are effectively and immediately defamed. In British society, a great many people will concur that individuals are obviously disparaged on the premise of their race, society, financial status, sex and age. Notwithstanding, the presence of disgrace can be more treacherous when connected to those with physical and dysfunctional behaviour, inability or physical impedances, or when connected with ugliness, indiscrimination, kid/grown-up ill-use, same-sex introduction, medication utilization/misuse and passing. Once derided, the individual is discriminated as a worthy part of society, subsequently the expression “ruined personality” stated by Pearson et al., (2009) to depict the division of the deprived individuals from “ordinary” parts of society. Once named as an “other,” the slandered individual is then subjected to separation, the activity emulating the cognitive methodology of derision. 
LO1: Characteristics of Quantitative and Qualitative research methods
It has been stated that in the current era of Modern science there are multiple ways of thinking and identifying qualitative and quantitative research. The disagreement between qualitative examination methodologies and other research techniques is in inconsistency with the methodological aspects, as well as shows up in the opposition, in the epistemological field. This implies that the instruments, as well as in the focal methodologies describe the generation of information. I accept that the qualitative epistemology is focused around standards that have vital methodological outcomes. Alternately, quantitative outline addresses the numerical delineation of proof examined and information gathered.

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Logical information from qualitative exploration is not legitimized by the quantity of subjects examined, however by the nature of its outflow (Bernard & Bernard, 2013). The quantity of subjects to study reacts to a quantitative paradigm, characterized essentially by the needs of the learning procedure found sometime during the examination in factual means. Singular statement of the subject in both the techniques gets centrality as the spot which may have at one point for the generation of thoughts by the analyst. The data passed on by a specific subject can be a critical minute for the generation of learning, without essentially must be rehashed in different subjects and information gathering techniques.
Qualitative exploration offers numerous perspectives with quantitative examination morals. Along these lines, the moral issues are appropriate to science as a rule to both the examination plans. Clearly, knowing the multifaceted nature of morals and good logic, it is prescribed that an exchange that is expected to approach moral judgements of qualitative examination ought to be upheld by a few hypotheses. At the same time there are such a variety of hypotheses that a well meaning push to actualize large portions of them in the investigation of a particular examination can get to be inefficient.
Especially on account of quantitative exploration, it is important to incorporate individuals with capacity and readiness of reflection and correspondence that they comprehend social qualities, needs and powerlessness, and the concerns of potential study subjects (Bernard & Bernard, 2013). Leading qualitative exploration is similarly less immoderate than directing quantitative examination. Qualitative research likewise turns out to be viable when the exploration obliges unlimited measure of data.
LO2: Is Research evidence appropriate to health and social care practice
Since the first instances of AIDS were distinguished in 1981, HIVs have been disparaged. The examination confirmation existed on this point involves to the broad accessibility of information and databases. Cao et al., (2010) recommended that in social and medicinal services connection, the dread of AIDS spread over our country, HIVs being deprived from their occupations, ousted from their homes, denied restorative tend to, savagery and expelled from their own particular families. Additionally, HIV-positive kids have been denied admission to schools, games groups and clubs, and have encountered badgering from other youngsters and folks of other kids. This social derision of HIVs is not restricted to the United Kingdom, either.
In different nations, HIVs have been beaten to death; disregarded by neighbours, managers and social insurance specialists; and even compared to rehearsing witchcraft. As a result of its relationship with the unthinkable subject of male-to-male sex and the trepidation of tainting, society has reacted to HIV/AIDS by disparaging persons to avoid them as much as possible. Is this belittling got from outsiders, as well as it can be gotten from the HIV’s relatives, companions and health awareness experts too. It is interesting to note that during an era when HIVs need social backing like never before, they are rather subjected to the threatening vibe and dismissal connected with HIV-related disgrace.
Radcliffe et al., (2010) characterized the expression “Helps related shame” as “a term that alludes to preference, reducing, undermining, and segregation guided at individuals saw to have AIDS or HIV, and the people, gatherings, and groups with which they are related”. This belittling can be showed in numerous diverse ways, frequently focused around the current generalizations of the society. In the United Kingdom, HIV-related disgrace showed through seclusion, dismissal, stereotyping, segregation and off and on again savagery. Social Factors of HIV-Related Stigma HIV/ AIDS confront shame on numerous distinctive levels. Medicinal diseases as of now can be a disgrace of their own, particularly focused around the reality of the condition.
Since there is right now no cure for HIV/ AIDS, the condition is viewed as “deadly,” a term which strikes fear in the hearts of the vast majority. In an examination article on “Supports and Stigma,” Wagner et al., (2010) demonstrates that there are four particular qualities of HIV/AIDS that inspire disgrace from society, specifically: 1) apparent obligation of the PWHIV in getting the illness, 2) the “unalterable or degenerative” nature of the malady, 3) the way that it can be an infectious infection and 4) the promptly obvious indications of the sickness which show as the ailment advances. Rao et al., (2012) draw a qualification between “instrumental AIDS disgrace” (identifying with the transmittable and deadly nature of HIV) and “typical AIDS shame”. Instrumental AIDS shame is an after-effect of society’s characteristic apprehension of the illness and the absence of instruction on infection transmission.
LO3: Examining research evidence with consideration to validity and reliability
In assessing studies, numerous methodological concerns do develop. Maybe, the most vital concerns are reliability and validity of the exploration procedure. Reliability appraisal of a study device is a centre segment of behavioural research and can be used effectively into immediate perceptions by deciding best conceivable levels of presentation. A few strategies have been utilized that can give reliability of the survey estimation routines, including test-retest, Pearson coefficient, Kendall’s coefficient, odd-even, and the proportional structures strategy. Social approval systems are substantial to the degree that they gauge what they claim to quantify. It is basic that great inward and outer validity be expressed as a social approval method. In addition, the outside validity of the evaluation methodology can be evaluated and still is faulty (Ritchie et al., 2013). The measurements analysts accept they are measuring may have little connection to what is really being measured and that face validity is deficient as the sole paradigm for assessing the validity of appraisal gadgets.
One approach to survey validity would be to have the social approval evaluation created or reassessed by a board of masters or judges who are not included straightforwardly in the examination. An alternate technique would be to have a social approval evaluation of the social acceptance instrument. Case in point, in the wake of reacting to a poll, raters would react to a second survey that let them know the reason for the first survey and requested that the rate how well they thought the inquiries surveyed the reason (Ritchie et al., 2013). Also, analysts need to be mindful of radiance impacts, inclinations to tolerance or seriousness, focal propensity reactions, and position or closeness predispositions of raters, which might misleadingly improve the reliability of estimation without enhancing reaction exactness or validity.
LO4: Demonstrate knowledge of the relationship between research theory and health and social care practice
Investigation demonstrates that social help whether perceived or genuine is especially paramount for females as they depend all the more on social connections contrasted with men in comparable circumstances. A few studies have recommended that apparent social backing is more vital than genuine backing. Social backing has been demonstrated to impact both well being conduct and well being conclusions. Further, social backing has been indicated to cradle the impact of natural stressors, in this way, minimizing antagonistic results of upsetting circumstances. There is an overall reported backwards relationship between social backing and misery among HIV-positive populaces. Albeit much is thought about HIV-related shame and HIV-divulgence, an audit of the writing uncovers an absence of understanding of how they influence misery. Consequently, the general objective of this study is to look at the connections between sorrow (a mental result of HIV illness) and HIV-related shame, exposure of HIV positive status, and social backing among African-American ladies with HIV infection.
Cao et al., (2010) portrayed social backing as an indispensable asset that an individual must draw upon for survival. As a safety asset, social backing is hypothesized to have an immediate impact on both cognitive evaluation and adapting endeavours. Social backing can help more positive examinations of individual life circumstances and backing more powerful adapting. Social backing can serve to lessen instability and stress and give the individual a method for diversion, passionate help, sensitivity and sympathy, and accommodating data. Ritchie et al., (2013) further developed the idea of social help, expressing that there is an agreeable refinement between the number and sorts of social connections and the view of the estimation of such connections. The quantity of social connections is termed the informal community.
The view of social connections is termed seen social backing. At long last, Ritchie et al., (2013) recommended that there are distinctive sorts of social backing, for example, passionate, instructive, or substantial, and the sort of help must additionally be considered notwithstanding the span of the informal community and the impression of the nature of help that is accessible. Cao et al., (2010) remarkable various studies that have demonstrated how social connections maintain wellbeing and on the other hand how low social help identifies with negative wellbeing results.
Broad exploration has showed that social combination has significant physical and mental medical advantages for more established grown-ups. What’s more, social backing has been indicated to be identified with positive conclusions in individuals living with HIV and, all the more particularly, to gay men living with HIV. Actually, adults matured 50 years and more seasoned include in excess of 10% of the HIV-positive populace in the United Kingdom. This rate is most likely excessively low focused around the way that more established grown-ups are rarely tried for HIV.
Not their doctors or the more established grown-ups themselves see that they are at danger for the sickness. This is further convoluted on the grounds that numerous manifestations of HIV can be camouflaged as results of maturing. Alongside ladies and minorities, more seasoned grown-ups are right now one of the quickest developing HIV-contaminated populaces. They are particularly defenceless against disease (by physical changes in the body with age and by disappointment to utilize proper insurance amid sex) and, when tainted, they are more averse to recognize the side effects, get tired and look for the help they require.
LO5: Gather evidence from a variety of research sources, including charts, graphs and tables, from text and online sources
Although, emotional distress serves as a motivator for help-seeking behavior, the fear of being stigmatized may cloud the person’s cognitive process of making the decision to seek help. As time is of the essence with HIV/ AIDS, this delay in seeking health or social services presents a real problem.

HIV/AIDS cases are also on the rise in such marginalized groups as African-Americans, women and older adults. Therefore, in many cases, HIVs are already stigmatized prior to disclosure of their HIV-positive condition. They know all too well the results of being stigmatized and, therefore, may be even more unwilling to disclose their HIV-positive status.

The HIV-related stigma, then, becomes a second or even third type of stigma that is forced upon them. In their study of HIV-related stigma received by African-American caregivers, Rudolph et al., (2010) stated that “social isolation stemming from HIV-related stigma may be exacerbated for women, for elderly people, and for people of colour”.

Persons who get HIV through circumstances which were out of their control (i.e., blood transfusions, needle-sticks or mother-to-kid) are even subject to this kind of slander, particularly as their infection advances. Typical AIDS shame is a statement of the general public’s negative state of mind connected with the transmission of HIV. Due to the way of HIV/ AIDS, it will in the end get to be important for the contaminated individual to look for restorative consideration, at any rate. The forceful enthusiastic impacts going with the ailment might likewise make the requirement for usage of social administrations.. As time is of the pith with HIV/ AIDS, this deferral in looking for well being or social administrations exhibits a genuine issue. To confound matters, more established grown-ups and some ethnic gatherings are now uncertain of western solution hones, human services associations and mental health administrations and, moreover, might not have equivalent access to these administrations. Albeit one may think divulgence to administration suppliers may not act like incredible a danger of being criticized as exposure to family, companions or associates, it still has dangers.

Conclusion
Since, the situation of HIV/ AIDS, is inevitably vital for the HIV-positive individuals to look for restorative consideration, at any rate, the compelling passionate impacts going with the disease might likewise make the requirement for use of social administrations. To entangle matters, more established grown-ups and some ethnic gatherings are as of now uncertain of western medication hones, human services associations and mental health administrations and, moreover, might not have equivalent access to these administrations. Albeit one may think deprivation to administration suppliers may not act like incredible a danger of being derided as exposure to family, companions or associates, it still has dangers. Notwithstanding the hazard that the HIV’s status may not be kept totally private, there is likewise the danger of being defamed by the very administration experts to whom the HIV’s turns for help. Despite the fact that health awareness experts may not have any desire to confess to slandering HIVs, the examination has confirm that HIV-related shame keeps on being available among some of them (Wagner et al., 2010). Notwithstanding the solid impact HIV-related disgrace can have on the self, it is characteristic for individuals to oppose being disparaged, and in this way, the social shame of HIV/ AIDS may make unnecessary deterrents to get social and health awareness administrations. On the off chance that the HIV’s urge to oppose defamation is stronger than their urge to look for help for themselves, they may evade usage of HIV-related administrations until such time that they cannot maintain a strategic distance from it any longer, maybe because of a hospitalization.
References
Bernard, H. R., & Bernard, H. R. (2013).Social research methods: Qualitative and quantitative approaches. Sage.
Cao, H., He, N., Jiang, Q., Yang, M., Liu, Z., Gao, M., … & Detels, R. (2010). Stigma against HIV-infected persons among migrant women living in Shanghai, China.AIDS Education and Prevention,22(5), 445.
Pearson, C. R., Micek, M. A., Pfeiffer, J., Montoya, P., Matediane, E., Jonasse, T., … & Gloyd, S. S. (2009). One year after ART initiation: psychosocial factors associated with stigma among HIV-positive Mozambicans.AIDS and Behavior,13(6), 1189-1196.
Radcliffe, J., Doty, N., Hawkins, L. A., Gaskins, C. S., Beidas, R., & Rudy, B. J. (2010). Stigma and sexual health risk in HIV-positive African American young men who have sex with men.AIDS patient care and STDs,24(8), 493-499.
Rao, D., Feldman, B. J., Fredericksen, R. J., Crane, P. K., Simoni, J. M., Kitahata, M. M., & Crane, H. M. (2012). A structural equation model of HIV-related stigma, depressive symptoms, and medication adherence.AIDS and Behavior,16(3), 711-716.
Ritchie, J., Lewis, J., Nicholls, C. M., & Ormston, R. (Eds.). (2013).Qualitative research practice: A guide for social science students and researchers. Sage.
Roura, M., Urassa, M., Busza, J., Mbata, D., Wringe, A., & Zaba, B. (2009). Scaling up stigma? The effects of antiretroviral roll-out on stigma and HIV testing. Early evidence from rural Tanzania.Sexually transmitted infections,85(4), 308-312.
Rudolph, A. E., Davis, W. W., Quan, V. M., Ha, T. V., Minh, N. L., Gregowski, A., … & Go, V. (2012). Perceptions of community-and family-level injection drug user (IDU)-and HIV-related stigma, disclosure decisions and experiences with layered stigma among HIV-positive IDUs in Vietnam.AIDS care,24(2), 239-244.
Wagner, A. C., Hart, T. A., Mohammed, S., Ivanova, E., Wong, J., & Loutfy, M. R. (2010). Correlates of HIV stigma in HIV-positive women.Archives of women’s mental health,13(3), 207-214.
 

The Issue with Stigma and Depression

The Issue with Stigma and Depression

Depression is a growing health issue affecting thousands of people across the globe and was ranked as the third cause of burden of disease worldwide (Malhi & Mann, 2018). It has been predicted that by 2030, major depression will be ranked the first cause of burden of disease (Malhi & Mann, 2018). Depression is a mental health disorder that has been described as an incapacitating disease that generates a greater diminishment in health than chronic diseases such as asthma and arthritis (Sia et al., 2018). The most recent National Health Survey conducted between 2017 to 2018 established that just over one in five or 20.1% of Australians had a mental or behavioural condition, a significant increase from 17.5% in 2014 to 2015 (Australian Bureau of Statistic, 2015; Australian Bureau of Statistic, 2018). A further 1 in 10 people (10.4%) reported having depression or feelings of depression which was an increase from the 8.9% reported in the 2014 to 2015 survey (Australian Bureau of Statistic, 2015; Australian Bureau of Statistic, 2018). Of solicitude, in a figure representing only 16% of Australians experiencing mental illness, as little as 41% of those on active treatment reported having received marginally satisfactory treatment (Sia et al., 2018).

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In this report, provided first will be an evidence-based description of depression, succeeded by its determinants focusing on the society, culture and environment. Subsequently, to show that the increasing population of Australians experiencing depression and the inadequate number of those seeking help is of great concern, a symbolic interactionalist theory will be applied, demonstrating that it is due to the stigmatisation of mental illness in Australia that this issue has emanated. This will support a recommendation that education programs, public campaigns and the depiction and portrayal of depression in the media should be considered to help reduce the stigma and encourage individuals to seek professional medical help.

The major issue in concern for Australia is not so much depression itself, but rather the challenge of suffering individuals not seeking medical help due to the stigma associated with it and thus the possible physical risks associated. Depression, in definition as a disorder, is depended upon the symptoms causing functional impairment for an individual (Malhi & Mann, 2018). Symptoms of depression can be predominantly grouped into emotional, neurovegetative and cognitive categories (Malhi & Mann, 2018). One thing to note is that depression is not the same as unhappiness or typical feelings of sadness (Malhi & Mann, 2018). To be diagnosed with depression and individual must demonstrate five or more identified symptoms almost every day for a two-week episode (Malhi & Mann, 2018). Diagnosis can happen after one episode however, if depressive episode continues for extended periods of time, the diagnosis can be described as chronic depression, or if symptoms persist consistently for 2 years it can be termed ‘persistent depressive disorder’ (Malhi & Mann, 2018). Symptoms of depression often include fatigue, hopelessness, insomnia, eating problems, anhedonia, and shame and guilt (Malhi & Mann, 2018; Ward, 1995). In Australia, approximately one in 10 people suffer from depression (Australian Bureau of Statistic, 2015; Australian Bureau of Statistic, 2018). In westernised society, stigma is one of the leading challenges faced by individuals with mental health issues (Wood et al., 2014). According to a study conducted by the Australian and New Zealand Journal of Psychiatry, two in three people meeting the criteria for a mental disorder did not seek help in any one year (Reavley et al., 2011). Stigmatisation is this idea of social disapproval and negative ideas about specific groups of people based on their physical or mental characteristics and lifestyle (Gaebel, Roessler & Sartorius, 2016). Stigmatisation can lead to such problems as exclusion of individuals from contributing in various areas of social life (Gaebel, Roessler & Sartorius, 2016). A study conducted at four medical universities in Australia found that four-fifths of students demonstrated stigmatised beliefs about depression with ideas following the perception that depression is not a real medical illness but a sign of personal weakness and that an individual can snap out of it if they want (Gaebel, Roessler & Sartorius, 2016; Beyondblue, 2015). These general attitudes and beliefs contribute to a vicious cycle of individuals suffering depression not getting help to avoid the stigma and thus to suffer relapses and fall into a deeper depressive state which could lead to further mental health problems or even physical harm.

Depression can affect and person at anyone time regardless of their gender, age or class. It has been suggested that life events could possibly lead to the cause of major depressive disorder (Malhi & Mann, 2018). In adults and seniors these stressful life events could include life threatening illness, economic status, employment or bereavement which can cause psychological stress and make everyday task increasingly difficult (Malhi & Mann, 2018). In children these stressful life events could include neglect, abuse, learning difficulties and interactions in the schooling environment (Malhi & Mann, 2018). This demonstrates that the onset of depression or depressive episodes can occur at any stage in a person’s life course and may result from issues different from others suffering the same mental health issues. Regardless of what age, class or demographic a person is there is a stigma surrounding mental health and depression (Wood et al., 2014). However, a study comparing Australians public beliefs over the course of 15 years demonstrated that the depression literacy rate increase from 39% in 1995 to almost 75% in 2011 (Pilkington, Reavley & Jorm, 2013). This reveals that overtime Australia’s social and cultural determinants have improved yet the rate of suffering individuals actually seeking help is still at a low and is most likely a result of this stigmatised belief surrounding depression.

Adopting a symbolic interactionalist perspective, the lack of people speaking out about depression can be linked to the stigmatisation surrounding mental health. First, to understand how this theoretical perspective applies to the issue presented n the report, an understanding of symbolic interaction must first be established. Symbolic interactionalism is a sociological term used to describe interactions and social actions which are characterised by immediate reciprocal behaviour (Giddens & Turner, 1987). These processes of interaction can cause stress to the symbolic character of a social action (Giddens & Turner, 1987). This in terms of depression and stigma is the interaction of people not wanting to reach out and speak about mental health issues. As mentioned previously in this report, most individuals suffering from depression do not seek medical help as mental illness is perceived as a stigmatising disorder and can lead to self-stigma (Gaebel, Roessler & Sartorius, 2016). This issue of people not wanting the stigma associated with them means they received less effective therapy and can suffer unfavourable prognosis and relapses (Gaebel, Roessler & Sartorius, 2016). Self-stigma is also known to lower self-esteem and can hinder and individual’s performance in both their home and work life (Gaebel, Roessler & Sartorius, 2016). Originally stigma use to be defined as having a trait or characteristic that reduces an individual from a ‘whole person’ to a tainted person (Wood et al., 2014). Hence this idea of being consider by society as a lesser person can really impact an individual’s decision to seek help. A study conducted at various universities around Australia supports this negative stigma idea and concluded from their results that students who experienced greater levels of stigma from close relationships were significantly less likely to get assistance and talk about their depression with even fewer even disclosing that they have a mental health issue (Gulliver et al., 2019). This study found that the majority who did not speak out about having a mental health issue reasoned their actions to fear of not wanting a label (Gulliver et al., 2019). Focusing even more closely to depression is that, when compared to other mental illnesses, depression is perceived with more negative stereotypes such as being lazy and difficult to talk to (Wood et al., 2014). This could also induce social stigma meaning and individual is perceived as different and can cause discrimination amongst suffers (Haddad P. & Haddad I., 2015). This stigma and associated stereotypes created by society are highly discouraging for individuals suffering depression to actually want to speak out and receive help.

It is clearly presented by research and studies that stigma is the leading cause for individuals suffering depression to not speak up about their experiences and thus recommendations such as school-based programs, campaigns, media representations and legal action should be considered when looking to reduce Australia’s high rate of depression. It has been suggested that introducing interventions that reduce exposure to environmental determinants of depression would reduce discrimination faced caused by the stigma behind mental illness (Sia et al., 2018). One suggestion is to introduced school-based prevention interventions in which youths will learn from a young age how to deal with the illness if someone they know or themselves are suffering depression (Lee et al., 2017). This will also lessen the stigmatisation about depression and other mental illnesses as early exposure will normalise these conditions and can reduce school-based discrimination (Lee et al., 2017). The second endorsement to be made is to introduce new public campaigns that educate society more about how to respond to a person who is suffering from depression. It has been suggested that targeting the mean population mood with these campaigns could reduce the prevalence of depression (Sia et al., 2018). The populations mood and attitudes towards depression if improved may encourage more people to reach out and get help if they’re suffering (Sia et al., 2018). Thus far there have been no preventative mental health policies in Australia which have targeted the mean mood of the population (Sia et al., 2018). Study results from the ‘Changing Minds Campaign’ which ran between 1197 and 2003 in the UK demonstrated a reduction in negative attitudes towards mental illness and an overall lessened stigma by developing a public and professional understanding of mental health problems (Wood et al., 2014). The survey results advocate that over time greater recognition of depression and the ratings of interventions like help from mental health professionals have improved (Reavley et al., 2011). These results demonstrate just how effective campaigns can be at reducing stigma through social contact interventions (Haddad P. & Haddad I., 2015). A third proposal to be made is to target the media to depict a more accurate representation of people suffering depression. The fictional portrayal of individuals with mental illness in movies and television creates stereotypes that can be misleading and stigmatising (Haddad P. & Haddad I., 2015). This can cause society to view these individuals in a negative light and increase discrimination based on false information (Haddad P. & Haddad I., 2015). If this dramatization of mental illness in media can be reduced to represent accurate characteristics and symptoms then it will increase understanding in the public and decrease the stigma surrounding depression. The final proposal to help reduce stigma and discrimination associated with it is to introduce policy and legislation to deal with it.

With depression being one of the leading causes of burden of disease not only in Australia but on a global scale, its time we start to revaluate our beliefs of mental illness as a society to encourage individuals suffering depression to seek help. Through the evaluation of social, cultural and environmental determinants of depression and the adoption of a symbolic interactionalist view, it can be understood that the leading reason for the inadequate number of individuals seeking professional help is due to the stigmatisation of mental illness and the negative stereotypes associated with depression. Through the introduction of school-based education programs, public campaigns and positive media representation the stigma surrounding mental health can be greatly reduced, thus encouraging individuals to pursue help.

Australian Bureau of Statistics. National Health Survey: First Results, 2017-18. Canberra, Australia: Australian Bureau of Statistics; 2018 Dec Available from: https://www.abs.gov.au/ausstats/abs@.nsf/mf/4364.0.55.001

Australian Bureau of Statistics. National Health Survey: Mental Health and co-existing physical health conditions, Australia, 2014 – 15. Canberra, Australia: Australian Bureau of Statistics; 2015 Dec Available from: https://www.abs.gov.au/ausstats/abs@.nsf/0/C0A4290EF1E7E7FDCA257F1E001C0B84?Opendocument

Beyondblue. (2015). Beyondblue Information Paper: Stigma and discrimination associated with depression and anxiety (pp. 2-16). Australia: Beyondblue. Retrieved from https://www.beyondblue.org.au/docs/default-source/policy-submissions/stigma-and-discrimination-associated-with-depression-and-anxiety.pdf

Gaebel, W., Roessler, W., & Sartorius, N. (2016). Mental Illness Stigma: End of the Story? Cham: Springer.

Giddens, A., & Turner, J. (1987). Social Theory Today (pp. 82-92). [eBook]. California: Stanford University Press. Retrieved from https://books.google.com.au/books?hl=en&lr=&id=DsOEjreGrNEC&oi=fnd&pg=PA82&dq=symbolic+interactionism+sociological+definition&ots=hkdpK_zSPV&sig=i7Br-G7X5CBfUbEK5aS00J8ZEbw#v=onepage&q=symbolic%20interactionism%20sociological%20definition&f=false

Gulliver, A., Farrer, L., Bennett, K., & Griffiths, K. (2019). University staff mental health literacy, stigma and their experience of students with mental health problems. Journal of Further and Higher Education, 43(3), 434-442.

Haddad, P., & Haddad, I. (2015). Mental Health Stigma. Retrieved 12 October 2019, from https://www.bap.org.uk/articles/mental-health-stigma/

Lee, Y., Barendregt, J., Stockings, E., Ferrari, A., Whiteford, H., Patton, G., & Mihalopoulos, C. (2017). The population cost-effectiveness of delivering universal and indicated school-based interventions to prevent the onset of major depression among youth in Australia. Epidemiology and Psychiatric Sciences, 26(5), 545-564.

Malhi, G., & Mann, J. (2018). Depression. [eBook]. The Lancet, 392(10161), 2299-2312. Retrieved from https://doi-org.ezproxy.library.uq.edu.au/10.1016/S0140-6736(18)31948-2

Pilkington, P., Reavley, N., & Jorm, A. (2013). The Australian public’s beliefs about the causes of depression: Associated factors and changes over 16 years. Journal of Affective Disorders, 150(2), 356-362.

Reavley, N., Jorm, A., Cvetkovski, S., & Mackinnon, A. (2011). National Depression and Anxiety Indices for Australia. Australian and New Zealand Journal of Psychiatry, 45(9), 780-787.

Sia, A., Williams, L., Pasco, J., Jacka, F., Brennan-Olsen, S., & Veerman, J. (2018). The Population Mean Mood Predicts The Prevalence of Depression in an Australian Context. Australian & New Zealand Journal of Psychiatry, 52(5), 461-472.

Ward, A. (1995). Symptoms of depression: Charles G. Costello (Ed.): Wiley, New York (1993). x 326 pp. £29.95. Behaviour Research and Therapy, 33(5), 615.

Wood, L., Birtel, M., Alsawy, S., Pyle, M., & Morrison, A. (2014). Public perceptions of stigma towards people with schizophrenia, depression, and anxiety. Psychiatry Research, 220(1-2), 604-608.

 

HIV/AIDS And Stigma | Essay

HIV/AIDS is one of the challenges to human life and dignity. It affects all levels of society and has a massive impact on global economic and social development, (Rowden, 2009). Studies have been conducted on its impact on human life and how it could be controlled. This review was conducted by exploring literature from a variety of sources for published articles on HIV/AIDS and its stigma. Literature from research covering a period of 8 years from 2002-2010 was extracted from Assia, PubMed, Sage, British Medical Journal, Cochrane and Absco-host, and reviewed for the study, objectives, methodology and key findings. Relevant books, journals, documents and reports from organisations such as UNAIDS, and the World Bank were also reviewed. Both qualitative and quantitative data was used to present the information.

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Despite facing a lot of criticism on its top-down approach, the biomedical model remains the dominant concept in health and illness. Its credibility lies on its scientific methods and expert knowledge used to diagnose or understand illness and treatment. This model views the body as a machine composed of different parts working together for it to function. If one part is not functioning properly, the aim is to find what is wrong with it through diagnosis and fix it by prescribing medicine, (Taylor &Hawley 2010:12). Focus is therefore restricted to the physical illness of an individual’s body and the scientific understanding of disease, making the approach heavily based on pharmacology. While pharmacology is beneficial in the treatment and prevention of HIV/AIDS, it is criticised for promoting the privilege of the biomedical model, further enhancing undermining of alternative approaches to health and healing. The biomedical approach may be inappropriate to some communities and create feelings of helplessness and vulnerability therefore affecting the success of the intervention. (Global Health Watch, 2008, Farmer, 1999).
Lay concepts of health and illness are diverse and complex than those of the medical model. They focus on people’s experiences of health and illness in relation to their overall life experiences and are embedded within local social and cultural structures. Unlike in the biomedical approach, indigenous approaches seek to heal the whole person by linking the illness with the person’s social and economic background, (Taylor, 2003). However critics of this model argue that lay concepts are difficult to evidence and research hence they remain marginalised and scarcely recognised as legitimate knowledge, (Taylor &Hawley, 2010:13). On the contrary, Taylor, (2003) argues that lay perspective is crucial knowledge for public health as it identifies roots of illnesses for possible long term prevention and treatment for the larger population as compare to individually focused interventions.
Influence of power systems such as the dominance of the medical model hinder progress on preventions and treatment of diseases such as HIV/AIDS and stigma as they govern relationships between health structures and lay people. Goffman, (1990), and Parker and Aggleton, (2003),’s theories of stigma in helping us to understand how stigma is constructed and its influence in peoples’ lives view stigma and discrimination as functional systems which maintain boundaries between those in power and those without. Through such power, social inequalities are developed leading to creation of social norms. These formulate stigma by governing interactions between people and reinforce power structures that serve to maintain control of the powerless, (Farmer, 2005). Both theories have been widely used in HIV related stigma to highlight how prejudice, negative attitudes, abuse and maltreatment directed towards PLWHA have hindered the progress of prevention and treatment.
Research highlights that stigma and discrimination in health care settings deriving from social power imbalances contribute a great deal in keeping people away from accessing HIV/AIDS treatment and care. Patients felt greatly affected by health workers feeling uncomfortable with them and treating them in an inferior manner. In Tanzania, some discriminatory and stigmatised practices such as gossiping about patients’ HIV’s status, neglect, verbal abuse, testing and disclosing HIV’s status without consent were noted, (D.C Synergy, 2005). Similarly in India, health workers were disclosing patients’ HIV status to their families without patients’ consent, (Mahedra et, al, 2007). Harassment, avoiding and isolation of HIV-positive patients and testing without counselling are common features of stigmatisation in most studies. Some health workers wore protective clothing even if there was no physical contact during interactions. Fear of being identified as infected with HIV also influenced people to prolong testing for HIV and only accessed services when their illness was at an advanced stage, (Bond and Aggleton, 2002; Kinsler et al, 2007; Varga et al 2006; Kalichman and Simbayi, 2003). In Zambia, HIV-positive health workers were hiding their HIV status from their colleagues in fear of being stigmatised, (Dieleman et al, 2007).
While most of the literature on HIV/AIDS and access to health services is negative, there is evidence of the value of supportive and de-stigmatising HIV services in some parts of the globe. Brazil has been hailed as a model by PLWHA. They reported supportive inclusive structural systems that create healthy environments that promote active participation of different groups in society and the government, (Caltado, 2008). In South Africa where most people believe in traditional healing, Aids Activism has made a positive significance in HIV/AIDS prevention and treatment by translating and mediating the biomedical approach within local ideological frameworks which are easily understood and acted on by the locals, (Colvin, Robins, 2010).
Literature reveals that collaboration between lay perspectives and biomedical approach is essential for successful control of HIV/AIDS and stigma. There is no cure for AIDS but Anti-retrovirals (ARVs) can prolong life by lowering levels of HIV in the body therefore delaying the process between HIV and AIDS, (Robin, 2009). Although ARVs are now readily available in most countries, numbers of newly infected people are rising. According to the World Bank, 60 million people are living with HIV/AIDS worldwide. Access to treatment has increased dramatically but for every 100 people on treatment, 250 become newly infected, (World Bank, 2010). As such, pressure is now rising on the effectiveness of only relying on the biomedical approach for treatment and care of HIV/AIDS.
While lay perspectives are considered effective, this cannot be confirmed as true with HIV/AIDS care. In South Africa, despite people heavily relying on traditional healing approaches, HIV prevalence continued to rise. Significance towards effective control of the epidemic has been noted with the increase in accessibility of ARV’s, (Colvin, 2009). In the UNAIDS Report On The Global AIDS Epidemic 2010, in 7 countries, five of them in Eastern Europe and Central Asia, HIV incidences increased by more than 25% between 2001 and 2009. Sub Saharan Africa, although still remaining the most highly affected by the epidemic, figures either stabilised or showed signs of decline owing to positive behaviour due to increased services that are embedded in local culture. The report affirms that stigma and discrimination, lack of access to services and bad laws can make the epidemic worse, (UNAIDS, 2010).
Due to the challenges presented by HIV/AIDS to global public health, Baum. (2008:241) calls for collective participation of all sectors in the fight against this deadly disease. She asserts that community level mobilisation where there is partnership between lay people and structures is the effective way of combating HIV/AIDS and stigma. This is further supported by Farmer, (1999:90), who does not condone the dominance of the biomedical perspective in health and healing. He believes that lay people have a significant role in the process of health improvements and emphasises on the importance understanding lay people’s experiences as essential knowledge for successful interventions. He holds that health care services should be accessible to PLWHA without fear of being stigmatised. Educating health care professionals about the impact of stigma on patients and policies that encourage inclusion of PLWHA in decisions that affect their lives are some of the key factors of effectively tackling the epidemic. Parker and Aggleton, (2003) also claim collective participation between lay people and health structures as key to successful anti-stigma services.
Relationships between health structures and PLWHA could also be improved by engaging lay people through advocacy. The Greater Involvement of PLWHA, (GIPA) principle emphasises the need for involvement of PLWHA at all levels in combating HIV/AIDS because they understand their situation better. Therefore their voices could be heard well if their needs were presented by people in the same situation, (UNAIDS, 2007). In the Zambia study, professionals living with HIV/AIDS are in a better position to advocate for people accessing services. Baum, (2008:550) affirms that advocacy involving public health practitioners is an effective way of influencing structural barriers in public health.
Literature has highlighted the contested nature of concepts of health and healing underpinning access to services providing treatment and prevention of HIV/AIDS and its stigma. The biomedical approach conceptualises health and illness through science and expertise with focus on the individual. Lay concepts view health and healing as embedded within local social and cultural structures and therefore seek to address public health for a wider population. Literature suggests that neither approach in isolation is effective in prevention and care for HIV/AIDS. Arguments have centred on the importance of collaboration of the models. Therefore there is need for intervention programmes to develop holistic approaches that are underpinned by the two models but it is also important to understanding each of the concepts in its own right.
 

Sociological Concepts of Stigma and Health Impacts

This essay is going to discuss the sociological idea of stigma and its effect on an individual, furthermore this essay will also define other concepts in relation to stigma such as the ‘Hidden Distress Model’. We will also discuss examples of this health illness in order to demonstrate the impact of stigmatization and their ‘Coping Strategies’. Moreover this essay will study how different individuals within society react to people with mental disabilities and other health illness for instance HIV and AIDS and how some individual in society find stigma more fearful than the condition they have been diagnosed in, for example a person who has been in a socially stigmatizing condition may feel discriminated and isolation and pain due to their illness.

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To address the issue of stigmatization, firstly it’s important to clarify whether or not there is a link between social integration and health. A study carried out by Berkman and Syme (1979) states the extent of individual’s integration within society has a significant effect on their health. In their research they identified two forms of ‘network scores’. They established that those with ‘low network scores’ had a higher mortality rate compared to those that had high ‘network scores’ (Nettleton 2006).
Stigma refers to a negatively well-defined condition, attribute, trait or behaviour conferring a deviant status which is socially, culturally or historically not the same. (Gabe et al, 2004). The word stigma was defined by the Greeks, they used the term to refer to the bodily signs a person had this could be cuts or burns. They intended the term to those whom they believed to be socially outsiders such as slaves or criminals, mainly those who were unhygienic or diseased would be avoided by people. (Gabe et al, 2004)
Goffman (1963) refers stigma as the difference between the virtual social identity, which is the stereotyped made in everyday life and the real social identity and stigma is the relationship between characteristics and stereotype. This two concepts – ‘Virtual Social Identity’ which is the stereotypes attributes we think we attain and ‘Actual Social Identity’ relates to the attributes an individual actually has.
We will pay particular attention to Actual Social Identity, this concept is when a person actually possess the signs of a stigma. Goffman says that ‘stigma is a special kind of relationship between attribute and stereotype’, and therefore people get stigmatized for the reason that their illness is obvious, for instance if a patient is deaf, blind or unable to walk therefore in a wheelchair or uses a hearing aid, in society they are seen as being abnormal because they don’t have the abilities of a normal person and for that reason they are socially undesirable or inferior also Goffman (1963) states ‘people with such ‘abnormalities’ are said to be stigmatized’ (Armstrong, 2003, p.42) . Although some illnesses can be obvious others can be relatively concealed, however they can still feel and ‘experience ‘felt stigma’ because they still see’ themselves to be inferior and they feel they are hiding a discreditable part of their personality from the outside world’ (Scamber and Hopkins, 1986, cited in Armstrong, 2003, p.42).
In today’s society the term stigma is used to refer to an individual who is culturally unacceptable with any condition, characteristic or behaviour (Gabe et al, 2004). According to Goffman (1968) his ideas added felt and enacted stigma, the former is the feeling that we are being discriminated against and the latter is actually being stigmatised through discrimination.
Goffman recognised three types of stigma that he explained as:

Stigma of the body, which relates to blemishes or physical deformities;
Stigma of character which relates to the mentally ill or criminals, and finally
Stigma associated with social factors which can be either racial or tribal throughout different cultures. Goffman goes on to say that his types of stigma can vary differently between social, cultural or historical environments (Goffman 1963, cited in Gabe et al., 2004, p.69).

While Goffman mentioned three types of stigma, Scambler mentioned two types of stigma. He combined his ideas in what he calls the ‘Hidden Distress Model’ which had been developed to explain the way in which an individual overcomes felt stigma in order to prevent experiences that play part of stigma. This, Scambler described it to be carried out by ‘Non-Disclosure’ which focuses attention on the fact that individuals would want to keep their condition from others in a hope to hide any information about their health condition and only will ever reveal their condition if it is necessary to do so. (Scambler, 2008).
The approach of the ‘Hidden Distress Model’ explains the reasons of the concealment of a condition, it is that because of the fear of associated stigma, moreover felt stigma is very easily seen so that one can avoid the occurrence of enacted stigma. Experiencing strong felt stigma could lead to higher stress which then leads to putting the patient harder circumstances in order to control their illness, which later on makes their illness worse over time due to the energy released through the concealment of their condition.
Moreover in relation to this Scambler (2008) states “Paradoxically, felt stigma is more disruptive of people’s lives and well-being than enacted stigma… ” he also says that felt stigma tends to increase the anxiety levels of an individual more so that enacted stigma.
To apply these concepts in real life circumstances, we will present how the avoidance of enacted stigma through felt stigma can worsen risks of various health issues ultimately deteriorating their health condition. Research study carried out on HIV and AIDS, has shown that people with such stigma are only known to their doctors and many chose not to kept it a secret and to disclose this information because of the way society thinks of AIDS and HIV. Patient might decide to avoid routine checks or treatment in the hope that they will not experience enacted stigma from others, for instance when they are entering or exiting the sexual health clinic or attending local HIV screening tests because of the stigmatising assumptions that are related to HIV /AIDS such as being gay or heavy drug user (Lubkin and Larson, 2012). Additional example can be seen with women who is avoiding screening for the sexually transmitted disease called HIV and AIDS for the fear of other people acting unreasonably towards them because they feel that they will be judged against behaviour associated with a lot of sexual partners. (Lubkin and Larson, 2012). And because this is associated with the person fearful of being treated different or labelled. People may not always seek medical help for their stigma conditions because of their fears of being faced with enacted stigma, however Zola (1973 has looked in to the timing of when individuals may decide to seek medical help, and in he discovered that majority of the people wait and put up with their symptoms for a while before they actually choose to seek medical assistance. Research study carried out on HIV and AIDS, has shown that people with such stigma are only known to their doctors and many chose not to kept it a secret and to disclose this information because of the way society thinks of AIDS and HIV.
As mentioned above avoidance of sexual health screening can lead to worsening health problems, a person with the health illnesses mentioned above could have life threatening diseases for the individual if he or she continue to express the ideas of the hidden distress model.
There are many studies that prove that is stigma is based on social concept. This study suggests that stigma is more about social concept rather than a characteristic of an individual. Parker and Aggleton (2003) ‘point out, processes of stigmatization remain part and parcel of processes of power, domination and discrimination; what becomes stigmatized is bound up with usual norms and values. Therefore it is socialized, not an individual, concepts (Nettleton, 2006, p.96). Therefore this study says felt stigma is more powerful than any accrual episodes of enacted stigma and for that reason it makes people more stigmatized.
Moving on to the concept of ‘Coping Strategies’ has been formed to explain the ways in which an individual copes with the effects of an illness. The term ‘coping’ refers to the “Cognitive processes whereby an individual learns to tolerate illness” and strategy relates to the actions people take in the face of illness (Bury 1991 cited in Nettleton 2006).
The term coping is used to maintain the feeling of self-worth and a sense of belief during an illness (Gerhardt 1989 cited in Bury 1991). The thought of normalisation can be used in ‘coping’ with an illness; this can be expressed in two with in the ‘Coping Strategies’. The first is to supress any negativity related to the illness so that the person can maintain their own personal identity which they held prior to their diagnosis; the second is to look at normalisation in terms of treatment where the treatment routine should not be remote place so that the individual can integrate with other people and not be isolated (Kellecher 1988, cited in Bury 1991). Bury (1991)
This further explains that it is the values of the individual that can determine how others respond to them in regards to their illness.
The model of ‘strategy’ is the actions that are taken in order to ‘maximise favourable outcomes’. (Bury, 1991). Moreover how a person responds to health illness experience regarding their condition does determine the extent to which they perform their strategies, the more negative experience they have can develop greater awareness in their everyday lives so as to escape or reduce the experience of enacted stigma. The controlling of illness through the use of strategies can differ from the influence of social settings to the forms that are developed in order to deter any focus to the condition as well as achieving set goals so that they can maintain their own sense of value and their belief of what their everyday life requires.
Goffman (1963) states that the way in which an individual copes with a stigmatising condition differs depending on the actual type of condition, he has specified two terms in relation to this – ‘discredited’ and ‘discreditable’; the first one is regarding an individual whose condition is widely known and the second refers to those whose condition is concealed. It’s described that those who have a discredited condition will find it harder to manage their stigma.
There are three different ways in which an individual can cope their own stigmatising condition the first is ‘Passing’ this is where one would try to fit in to the society as ‘normal’ usually the stigmatised individuals would constantly try to conceal their condition because they do not want anyone else to know if their illness; and for those with felt stigma are more likely to choose the passing approach for instance an individual with hard of hearing condition may decide to not use the hearing aid so that they can ‘fit in’ more with the society (Lubkin and Larson, 2012; Armstrong, 2003).
The second one is ‘Covering’ this refers to an individual with a discrediting attribute where they will try their utmost to conceal the significance of their stigmatising condition. (Goffman, 1963; Armstrong, 2003), in this situation the individual would try and take off the focus from his or her condition in order to avoid the experience of enacted stigma, the process could be amusing towards the situation which would reassure a less tense atmosphere making it to be more easy to manage (Lubkin and Larson, 2012).
Stigma is the result of a reaction expressed through the society that ultimately spoils identity of unacceptable norms that affect the stigmatised individual in a negative way. (Gabe et al, 2004). Nettleton (2006) states “Stigma is not an attribute of individuals, but is rather a thoroughly social concept which is generated, sustained and reproduced in the context of social inequalities.”
Some people are stigmatised because the part of the individual that is different is considered to be self-inflicted and in the ‘normal’ people’s eyes they are less worthy of help (Lubkin and Larson, 2012)
Parsons (1951) describes illness as a deviance form the norm and he also perceives illness as capable of cracking the social structure as the sick are unable to accomplish their social role within society. It can be expected that when an individual is sick they respond on the reaction of others, while society responds depending on the nature of the illness. (Lemert, 1967) suggests that there is three stages of deviance and he identifies these as primary deviance, which is related to an actual defined of a state or behaviour, and he claims that inside the law an action that was seen to be normal can become illegal or deviant, moreover secondary deviance refers to ‘the changes in behaviour that occur as a consequence of labelling’, for instance the stress of being discriminated and stereotyped can make an individual’s behaviour change over time. And the last stage is Tertiary deviance, which is the stigmatised individual’s reaction to the stigma from others leads to master status, for example categorising and stereotyping dominate individuals behaviours.
Scambler (2008) mentions that social factors is a major factor, which has impact people’s behaviour when they faced with what they recognize and recognise to be danger to their health and well-being. Freidson (1970) draws ‘societal reaction’ (Nettleton, 2006, p.73) furthermore he argues that there is three types of legitimacy. The first legitimacy is the ‘cases where it is achievable for a person to recover from illness, so they can get treatment for their condition, in addition their access to the sick role is conditional, the second is the incurable condition and their access to the sick role must be unconditionally, due to the fact that person might not get well and the last one is the illness being stigmatized by others and access to the sick role is to be treated as illegitimate (Nettleton, 2006, p.73).
According to Reidpath (2005) ‘ the fear of being stigmatized and subjected to discrimination many case some people to avoid or delay seeking medical help’ and this is because of fear, that people with stigmatized conditions feel socially isolated and often rejected moreover they are alienated in the society. For several stigmatized individuals, in order to to feel normal or socially accepted in the society they might join a talk group to form their own communities in order to meet people with similar issues (Armstrong, 2003). Many stigmatized people use copying mechanism in order to cope with their conditions and according to Goffman (1963) ‘a person with a stigmatizing condition could pursue several copying strategies that were largely based on the salience of the stigma he or her carried.
Scamber and Hopkins (1986), cited in Scamber, 2008, p.210, they described individuals ‘fearing discrimination, tend to conceal their epilepsy each time possible Certain ways they appear as normal included covering up their illness, a person with discrediting behaviour has no opportunity to go about it as normal but can still try to reduce the signs of his or her stigma and alternative way of passing as normal is managing expectations. This will l will lead the person to withdrawing from society and their social life, in order to avoid embarrassment and shame. An example people with conditions such as epilepsy, or HIV/Aids are able to hide away their condition when out in community, from partners, family and friends but they still do end up feel some kind of felt stigma due to them hiding some parts of their characters, nevertheless the individual way of avoiding social response to their illness and this is an case of passing as normal, concealing and managing expectations. People with stigma also get labelled unpleasant names such as handicap because they are being judged on their appearance and the abnormality they lack.
Conclusion
To conclude this essay, we agree with the idea of that felt stigma being more powerful than enacted stigma because individuals are more fearful of being stigmatized then the actually illness itself. This statement showed to be true by research studies that have been carried out this these areas. In this essay we have seen that before individuals are diagnosed with illness they prefer to hide from their illness and ignore their symptoms and refuse to seek medical attention they require also individuals develop fear of their community and the society because of their health condition, likewise they fear their family, friends look and treating them differently.
We have also looked into in to some research on stigma, we recognise why people are more fearful about the health condition than the illness because in society we tend to judge and isolate individuals on how they appear to look, before we even personally know them, for instance people in a with wheelchair we label them disabled. As Scrambler and Hopkins 1989, says that people with stigmatized illnesses are essentially outcasts and this is because they are socially rejected from society, due to their signs or symptoms and we see them as inferior. Nettleton (2006) suggests that illness reminds us that the normal functioning of our minds and is important to social action and relations with others, and this an significant fact and part of the reason proves why people are more fearful about their condition because they believe that people will be looking at them differently, judging and discriminating against them before it even happens. In addition to that we think people with serious health condition sexually transmitted diseases for instance HIV and AIDS should not tell their condition to others, for their own protection because some people have strong views and opinion on these conditions and these condition are associated with having many sexual partners and unhygienic. Scheff (1966) suggests that mental illness is a product of society’s opinions and reaction to the individual’s illness, we do believe that society’s has developed ways of just labelling people with all sort of illnesses especially people who are mentally ill and they are labelled as crazy and therefore they are treated different to others and stigmatized.
References
Armstrong, D. (2003) Outline of Sociology as Applied to Medicine 5thed. London: Arnold Publishers
Berkman, L. Syme, S. (1979) Social Networks, host resistance and mortality: a nine year follow up of Alameda County Residents. American Journal of Epidemiology 109 (2) pp. 186-204
Calnan, M. (1987) Health and illness. London: Tavistock
Bury, M. (2005) Health and illness. Cambridge : Polity Press
Bury, M, R. (1991) The Sociology of Chronic Illness: A Review of Research and Prospects’, Sociology of Health and Illness 13 (4) pp. 451-468
Gabe, J. Bury, M. Elston, A, M. (2004) Stigma, Key Concepts in Medical Sociology. London: Sage Publications pp. 68-69
Goffman, E. (1963) Stigma: Notes on the management of spoiled identity. New York: Simon & Schuster
Lubkin, M, I. Larson, D, P. (2012) Chronic Illness: Impact and Intervention Eighth Edition. Burlington: Jones and Bartlett Learning.
Nettleton, S. (2006) The Sociology of Health and Illness. Cambridge: Polity Press.
Scambler, G. (2008) Sociology as Applied to Medicine (eds.). Elsevier Limited.
 

Impact of Stigma on Access to Mental Health Care and Treatment

‘Role of stigma in limiting access to care and in discouraging people from pursuing mental health treatment’

 

Introduction

This paper will investigate the role of stigma in limiting access to care and in discouraging people from pursuing mental health treatment through a) epidemiology of mental illness, b) risk factors associated to mental illness, c) use of social constructionist perspective followed by the role of a social worker in assessing the risk and reducing the impact of stigma.

Mental health can be defined as “a state of well-being in which the individual realizes their abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to their own community” (World Health Organization, 2004, p.12). Mental Illness can be explained as “a health condition that changes a person’s thinking, feeling or behavior (or all three) and that causes the person distress and difficulty in functioning” Mental Health Foundation of Australia (https://www.mhfa.org.au/CMS/MentalHealthExplained)

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Over the period, service providers, analysts, and individuals with lived experiences in mental ailments have come together to create an evidence-based mediation that helps people accomplish life objectives.Even after the affirmation, people diagnosed with mental illness do not explore out treatment whenever they are in need or completely indulge themselves after the treatment or medication has started. Prejudice and discrimination may form the stigma and result in distinction between taking the treatment, continuing it or fully participating in taking medications

Stigma uncovers some part of the riddle why people may not want to participate in mental health treatment or leave the treatment early.

The two following obstructions identified with stigma may undermine need for seeking treatment and participate:

a) Individual level limits are the state of mind that impact wellbeing choices influenced by stigma, which may result in escaping the treatment, dropping out, poor well-being, treatment deficiency and absence of encouragement from people that underpins care seeking.

(b) System level limits comprise of the insufficiency of protection, monetaryrequirements, staff social inadequacy, and workforce constraints that are altogether influenced by stigma. (Association for Psychological Science, 2018).

Epidemiology of Mental Illness in Australia

Mental illness may have a weakening impact on the people and families, and critical driving effect on society. For those with intense conditions, it can obstruct altogether with a man’s intellectual, enthusiastic and social capacities and is much of the time related with financial weakness, joblessness or under-work, vagrancy and undermined efficiency. (Australian Institute of Health and Welfare, 2014, p.1)

‘One in five (20%) Australians aged 16-85 experiences a mental illness in any year. The most common mental illnesses are depressive, anxiety and substance use disorder’ (Australian Bureau of Statistics, 2009). The beginning of the mental disorder is frequently around mid-to-late puberty and Australian youth (18-24 years of age) have the most noteworthy pervasiveness of mental issue than some other age gathering and 54% of individuals with dysfunctional behavior don’t get to any treatment(Australian Institute of Health and Welfare, 2014).

The term ‘stigma’ characterizes a stamp or image of disfavor, and ‘to stigmatize’ intends to view a person as disgraceful. The repercussions of being viewed in such a way incorporate disgrace, debasement, exclusion, and debilitation. The weight of mental issue along these lines is considerably bigger, not simply by the immediate actualizes of stigmatization but rather by the incredible treachery in being thusly treated. It is standard to consider stigma to be basically a normal for others towards people with mental illness. Nonetheless, the procedure of self-stigmatization is a basic yet less obvious appearance of stigma that includes significant antagonistic consequences for the prosperity of the person with the psychological issue (Green, 2009).Differentiation has been made between ‘felt’ stigma and ‘enacted’ stigma (Scambler, 2005).

‘Felt’ stigma incorporates the general population having a dread of discrimination by other individuals and, ‘enacted’ stigma is the genuine articulation of segregation by other individuals towards the person.

Therefore, ‘felt’ stigma givesrise to camouflage image to create an impression one has on other people. In my opinion, this may be more hampering to people’s lives than of ‘enacted stigma.’

There has been a noteworthy change in seriousness of mental well-being sicknesses and the uniqueness of every person’s understanding of mental issue implies that help requests and utilization of administrations are likewise fluctuated.

The assessed populace treatment rate for individuals with mental scatters from the 2007 National Survey of Mental Health and Wellbeing was 35% (1.1 million individuals. 71% were asked to see general professionals (GPs), 38% counseled clinicians, and 23% counseled specialists. Eighty-six percent of those with a psychological illness who did not get emotional wellness care said that they saw no requirement for administrations, medicines, and care (“National Survey of Mental Health and Wellbeing: methods and key findings.” 2009)

 

Later investigation of regulatory information recommends that there has been a significant improvement on the generally low treatment rates saw in the 2007 National Survey of Mental Health and Wellbeing. The examination shows that the level of the populace with a current mental illness who got care in 2009– 10 was 46%, generously higher than the 35% gauge found by the ABS in 2007 (Australia’s health 2014, p.6). Australian government has concentrated on delivering a more extensive scope of services for those experiencing psychological battles, with a weight on helping people to remain well instead of giving help for the most part when they are in encounter. Projects like online treatment administrations for treatment of misery and nervousness, youth emotional wellness administrations, expressed based setup, and so forth are assuming an essential job in helping the people to come back to the network.

Risk Factors associated with Mental Illness

Mental wellbeing is controlled by a scope of natural, social and psychological variables like destitution and monetary impediment; separation and deficient social backings; vagrancy or insufficient lodging; physical, and profound wellbeing; availability of wellbeing administrations. In this manner, these all affect a man’s psychological well-being and their odds of creating emotional well-being issue(Zeanah, 2018).

Risk factors can be defined as contributing factors to an individual’s vulnerability to relapse, they occur through, factors, like – loneliness or isolation, difficulty communicating, chronic or severe mental illness, low self-esteem, anxiety, lack of family support, limited social network, lack of social identity, death of someone dear, divorce or family break up, unemployment, violence, cultural shock, stigma and discrimination, lack of support services, social and environmental barriers.

All domains of life can be a source of a risk factor to some or the other. However, it cannot be predicted to which extent any particular risk factor can contribute to an episode of mental illness.

However, by highlighting stigma as a potential risk factor could have an impact on individual and in result he/she could delay treatment seeking or continuing treatment which could further lead to a worse outcome, risk of relapse and increase in isolation.

The absence of mindfulness alone isn’t in charge of people to seek for treatment but the dread of being named as ‘rationally debilitated.’ Families being the emotionally supportive network realize that mental illness is a disease, yet tragically, assumption and disgrace meddles in looking for consideration as well as proceeding with it.

Without a doubt, stigma remains a potential risk factor for mental disorder and an obstruction in looking for consideration and proceeding with treatment.

Social constructionist perspective

 

The social constructionist view talks about the worries to mental disorder based on understanding the particular methodology an individual develops their reality to other people. Constructionism contends that something exists since society assembled it, made it or required it for its improvement or intrigue (Galbin, “An Introduction To Social Constructionism “, 2014, pp. 82 -92)

 

From this statement, it can be said that symptoms of mental illness can be seen as what society defines as ‘mental illness’ in a particular culture. Therefore, the social constructionist perspective could depend upon individual beliefs every society holds on what is normal or acceptable behavior as per the norm. For example, suicide in Indian society depicts ‘weak personality’ ‘mentally not strong’ while, in Japanese culture, suicide is an approach to make up for your transgressions. The indications of mental illness appear to be the essential focal point for enhancing personal satisfaction. As a glaring difference, the individual experience of stigma is unfavorable to the personal satisfaction, is once in a while given priority in the consideration and treatment by either the general public or mental health experts.

 

Stigma animates and expands social disengagement, averts treatment chasing by the individuals who require it. At times patients, carers and mental health professionals/ psychological experts express there individual occurrences of stigma, sometimes it is challenging to come to a conclusion whether the occasions are the proposed consequence of negative perspectives or discriminatory act has occurred (Carr & Halpin, “A Bulletin of the Low Prevalence Disorders Study”, 2002, p. 3)

 

Media additionally assumes an imperative job and is regularly condemned for the creation and broadcasting of stigmatizing demeanors on mental illness, and the facts demonstrate that people who have psychological sickness are depicted as ‘unsafe’ or ‘erratic’ by general society. In the British publication house, it isn’t surprising to peruse the labels like, ‘insane people,’ ‘psychos,’ ‘schizos’ in the daily papers (Carr & Halpin, “A Bulletin of the Low Prevalence Disorders Study”, 2002, p. 5)

The Commonwealth Government has undertaken a project to study inclusion of mental issue through the Media Monitoring Project.

Role of Social worker

Social workers are educated to recognize and determine that the mental disorders encountered by people, families, groups, and societies are not generated or influenced by a particular factor. Personal, educational, health, economic, employment or other societal factors can contribute and create hindrances to individuals. These factors are the central focus for social workers in supporting people with mental illness and helping them achieve positive wellbeing.

Social workers focus on investigating whether the change has to be made at an individualistic level or other spheres. Their practice in mental health across the spectrum holds different roles like a clinical social worker, case manager, therapist, family support worker, and rehabilitation worker. Social workers make use assessments to understand their client’s situation, problem, and strengths. They make use of professional knowledge to identify and assess relevant indicators to reduce risk for the client and others. Use of risk assessment and Mental State Exam are vital assessments in determining the risk. It includes a risk of self-harming behavior, vulnerability to violence, and other safety questions in the home and environment and level of the potentiality of their client to harm others and to analyze the requirement for psychiatry follow-up.

Social workers are the mediators, they can help in reducing the impact of stigma and bridge the gap between mental health professionals and individuals through stigma management. Through Mental Health Literacy Campaigns, social workers can use the educational strategy and encourage individuals and families to seek services.

Lastly, the strength-based approach can play a significant role in mental health recovery. Individuals have strengths within them, which can contribute to improvement. Helping clients in cultivating their interest, identify and build their strengths to achieve their goals could be a way to help them recover.

Conclusion

 

Personal and interpersonal stigma plays an important role in discouraging people from seeking and continuing mental health treatment. Addition to that, there are various risk factors associated with mental illness and stigma is highlighted as a significant risk. Through social constructionist perspective, it was observed that different cultures have a different perception about mental health and there’s a required need for awareness amongst mental health professionals for understanding the stigma and gaps in utilizing the services.

Use of risk assessment and MSE by the social worker is vital in identifying risk and catering to the needs of their client. Making use of literacy programs and strength-based approach could help in reducing the impact of stigma and encourage individuals in seeking and continuing care.

References

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Australian Institute of Health and Welfare. (2014). Australia’s Health 2014. AIHW: Canberra.

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Briggs, L., & Adamson, C. (2017). Supporting Wellbeing in Mental Health Practice. In M. Connolly, L. Harms, & J. Maidment (Eds.), Social work : contexts and practice (4th ed., pp. 192–204). South Melbourne, Victoria: Oxford University Press.

Connolly, M. (2013). Mental health social work in Australia. In M. Connolly & L. Harms (Eds.), Social work : contexts and practice (3rd ed., pp. 219–232). Oxford University Press.

Carr, V & Halpin, S. (2002). Stigma and discrimination A Bulletin of the Low Prevalence Disorders Study. National Survey of Mental Health and Wellbeing Bulletin 6, 6(0642 50349 4), .

McCann, Joseph (2016) Is mental illness socially constructed? Journal of Applied Psychology and Social Science, 2 (1). pp. 1-11.

Essays, UK. (November 2013). Is Mental Illness a Social Construction?. Retrieved from https://www.ukessays.com/essays/psychology/is-mental-illness-a social-construction-psychology-essay.php?vref=1

The Department of Health. (n.d.). Department of Health | Prevalence of mental disorders in the Australian population. Retrieved October 10, 2018, from http://www.health.gov.au/internet/publications/publishing.nsf/Content/mentalpubs-m-mhaust2-toc%7Emental-pubs-m-mhaust2-hig%7Emental-pubs-m-mhaust2-hig-pre

Shrivastava, A., Bureau, Y., Rewari, N., & Johnston, M. (2013). Clinical risk of stigma and discrimination of mental illnesses: Need for objective assessment and quantification. Indian Journal of Psychiatry, 55(2), 178 182. http://doi.org/10.4103/0019-5545.111459

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Reducing the Stigma Surrounding Mental Health in the Somali Community

Abstract
This paper focuses on mental health in the Somali community. Mental health has been considered a taboo topic within the Somali community for many years. In this paper we will discuss the importance of understanding mental health and the different health issues that are common amongst the community. With the stigma surrounding mental health individuals in the community to choose to ignore their mental health issues affecting their relationships with their families. In this paper we will also discuss the importance of bringing awareness into the community and the different resources that are available to the community in order for them to receive proper health care.  This paper also discusses the different programs that exist that have tried to help the community.
Introduction
Mental health does not exist on its own. It is an integral and essential part of overall health, which can be defined in at least three ways as the absence of disease, as a state of the organism that allows the full performance of all its functions or as a state of balance within oneself and between oneself and one’s physical and social environment (Bhugra, Till & Sartorius, 3). People in the community need to understand that even though they might think that they are healthy physically they also need to focus on their mental health as well. Mental health impacts other parts of their overall health as well. When mental health illnesses are ignored people tend to have a difficult time connecting with others forcing them to be isolated from their environment. Because of the traumatic experience that many Somalis’ in the community have experienced, they choose to ignore their illnesses since it isn’t visible to them.
Bringing the awareness of mental health issues into the Somali community allows people to discuss their mental health issues ending the stigma surrounding the issue, allowing people to receive proper health care services.
What is mental health
According to World Health Organization, Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make contribution to his or her community (World Health Organization, 2014). Mental health can affect a person’s daily life, relationships, and even their physical health. Mental health is away of describing how a person feels and how he or she manages to cope with their own emotions. Any severe illness of a family member creates stress for the rest of the family. The mental ill are unable to carry out a normal life pattern. Mental illness usually expresses its itself in a deviant behavior and in interpersonal difficulties causing family routines to be disrupted. Not only does mental illness remove a family member from the family it also causes change in family structure and function as a whole (John, C., Marian Y., 1955).
With many people in the community who have experienced the civil war they are prone to mental health issues. The civil war has had a huge impact on the community mentally and for some even physically.
There are two prevalent mental illnesses among the Somali refugees are Post Traumatic Stress Disorder and Depression (McCrone, P.,Stansfeld, S., Craig, T., Warfa, N., Curtis, S., Bhui, K., Mohamud, S., Thornicroft, G., 2006). A common illness that people who experience war go through is Post-traumatic stress disorder PTSD. . PTSD “is an anxiety disorder with exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following, directly experience the traumatic event, witnesses the traumatic event in person, learns that the traumatic event occurred to a close family member or close friend, or experiences first hand repeated or extreme exposure to aversive details about the traumatic event” (American Psychiatric Association, 2013). People with PTSD can experience flashbacks and exaggerated startled responses to normal stimuli (Warfa et al., 2006).
The second most prevalent mental illness in the Somali community is Depression. Depression is defined as having at least five of these nine symptoms: “irritable, decreased interest or pleasure, significant weight change, or change in appetite. Change in sleep, activity fatigue or loss of energy, guilt or worthlessness, lack of concentration, suicidality” (American Psychiatric Association, 2013).
The History of Somalia
The people of Somalia have traditionally been nomads, traveling between two main rivers as well as fishing around the coast (Warfa, et al., 2006). Around the mid-1800s, the country of Somalia has been colonized and divided by several foreign entities (Bhui et al., 2003). This included France, Great Britain, Italy, and Ethiopia. For generations, the people of Somalia have witnessed firsthand violence and wars. The violence lasted until 1991 then the civil war broke out. This civil war led to an estimated 400,000 deaths, as well as 45% of the population being displaced from their homes (Condon, 2006).

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Since the civil war began, the United Nations has reported that more than one million Somalis have left their country as refugees or asylees. Many Somalis started arriving in Minnesota in 1992 and as of 2018, Minnesota hosts one of the largest Somali communities in the Somali diaspora. In 2015, the Census data offered an estimate of 57,000. The majority of Somalis in Minnesota live in the Twin Cities metropolitan area, while others have settled in smaller towns throughout the state (MNOPEDIA, 2018). Because of the civil war families had to witness their lives torn be apart, relocated and uprooted to a foreign country forcing people to learn new languages and adapt to new cultures. Whole the culture they were adapting to new very little about their cultural and religious background. 
Relocation
Even though Somali people experienced the civil war they had to deal with the stressors of relocating as well. For that reason there is a high prevalence of Post-Traumatic Stress Disorder, Depression, and Generalized Anxiety Disorder in the Minnesota Somali population (Kroll, Yusuf, & Fujiwara, 2010). With experiencing such high levels of trauma this shows that Somali families are more likely to experience higher rates of mental health symptoms. Although exposure to traumatic events increases the risk for PTSD and other mental health problems, also multiple social, cultural, and family-related resources can moderate the association ( Mulki M., Saija K. , Marja T. , Marja-Liisa., and Raija-Leena Punam P., 2017). Even though service utilization is low among children, those from refugee backgrounds may be at greater risk for mental health problems and have greater difficulty accessing services (Linda P., Hillary. B., Abdirahman Y., Francine M., & Anita R., 2014). With the difficulty of accessing services its easier for people to ignore their symptoms and minimize their mental health issues that they might experience.
Being in a foreign country stops people from receiving the proper treatment that they actually need in order to treat their mental health. People have this mindset that they are outsiders in society, so they tend to stick with the community only and with the community refusing to acknowledge mental health issues makes it difficult for people to openly discuss their mental issues. The community needs people who are trained in the health care system who also could connect with the community without feeling like an outsider who is forcing themselves into the community. The community needs someone that they could trust and rely on when it comes to their issues. With a middle-man people are more like to report their health issues and receive the proper treatments that they need.
Parenting in a foreign country
In addition, to relocating to foreign countries, parenting has changed a lot for parents after moving to a foreign country. Being that the Somali community is a collectivist society it was considered that all the adults in the community help raise a child. The adults in the community has as much say in the child’s life as much as the immediate family. Whereas in the western culture the parenting style was more focused on the immediate family raising their child. With the Somali parenting style, children are allowed to run freely since any adult of the community is a part of raising the child (Guerin et al., 2004). If an adult outside of the immediate family finds a child behaving poorly, it is not uncommon for that adult to discipline the child (Guerin et al., 2004). While in the United States of America, it would usually be considered taboo for anyone other than the immediate family to provide discipline (Warfa et al., 2006).
In Somali of the key leaders in the community were considered to be the elders. Elders were considered to be the head of the household followed by the fathers. Elders were held in high positions regarding the decision making as well as the culture keepers in the community. Whereas, today, the roles have shifted, and families don’t rely on the elders as much as people did in Somalia. Looking at my own family I could see the change in family structure compared to when my mother was younger. My grandmother would tell me stories on how family structure is different compared to today’s and how families raise their children. Ln my immediate family my father is considered to be the provider and head of the household, but nothing happens without my mother’s approval. She always has the final say but my father believes that he is in control because he was raised and taught with the idea of the man being the household leader.
Parent Child Communication
As a result of parenting in a foreign country, raising a child in the U.S. has been difficult for parents especially since the roles have shifted. Upon coming to Minnesota, the elders have been taken out of their role due to not being able to adapt to the new way of life (Jaranson, et al., 2004). Because of this, there has been a role reversal where the children are now the experts (Jaranson, et al., 2004). With children being the experts, they have used it to their advantage. Often, due to the language barrier between the adults and schools, the children will act as interpreters and withhold information, thereby leaving the parents uniformed (Ali, 2008; Jaranson, et al., 2004). With the lack of accountability and supervision, this has caused further distress in the parents as well as the children, increasing the likelihood of developing mental illness.  
Barriers to health treatment
In the Somali community there isn’t a grey area when it comes to mental health, you are either sane or insane. When people suffer from mental illness they go to elders or religious leaders in the community in order to be cured or cleansed. Even though there is a need for mental health services there is still the issue of the stigma of mental illness in the culture. The cause of mental illness to the Somali community is often believed to be associated with evil spirit (Warfa, et al., 2006; Guerin, 2004). Somalis, are a very closed net community, they do not want anyone seeing them associated with mental illness, fearing that they will be stigmatized (Warfa, et al., 2006; Guerin, 2004). Because of this strong stigma, it is very hard to reach out to this culture (Warfa, et al., 2006; Guerin, 2004). Some of the reasons that make it hard for providers to reach out is that Somali’s view on mental illness being a challenge that god gave them, and therefore being their burden to carry and pray about (Ellis et al., 2010). It is difficult for people to ask for help, asking for help can be felt as being shameful because of it being their burden to work through (Ellis et al., 2010). The last reason that makes it hard to reach out is because of the stigma and potentially being viewed by the community as insane (Guerin et al., 2004).
Support and awareness in the Community
Furthermore, some of the current supports that the Somali community are religion, family, and community-based supports. Ellis, B. H., Lincoln, A. K., Charney, M. E., Ford-Paz, R., Benson, M., & Strunin, L., (2010) report that the Somali population will first look to religion for mental health support. Being that all of the Somali population is Muslim (Warfa, 2006). This proves that the mosques and other places of worship are major supports for the population. In the study by Ellis et al., they stated that families and family-based supports are considered supports, they reported that because of the stigma around mental illness, families have been shown to shun mentally ill members of the family even though they rely on family members for support.
Lastly, support is community- based, Somalis are unlikely to seek help from mental health clinics (Bentley, 2010). Medical clinics are more utilized because in the Somali culture it is not taboo to seek help for a physical symptom since the symptoms are visible (Ellis, et al., 2010). Even though there are not many, there are a few mental health clinics that specialize in work with the Somali population, such as the ‘Somali and East African Behavioral Health Services Program’ and ‘Somali Family and Youth Services Sabathani Center’, both located in Minneapolis, Minnesota (Volunteers of America Minnesota, 2014; Healing Resources for Refugees, 2014). The problem is these programs are being underutilized due to several barriers such as stigma and language difference between care providers and people in the community.
Places such as Summit Guidance in Saint Paul, MN provides a variety of services and programs including outpatient clinics, community-based support and rehabilitative programs, hospital liaison services, intensive family services, and long-term supports. Services are available to anyone. There specialty is caring for people with severe and persistent mental illness such as schizophrenia, major depression, post-traumatic stress disorder, and bipolar disorder and other severely disabling disorders requiring resolution long term or even ongoing treatment and support.
Additionally, there are programs such as Community University Health Care Center CUHCC in Minneapolis, who have been designed to help meet the needs of the Somali community. The clinic provides a wide range of outpatient’s services to the community. The different services include psychiatric assessment, medication management, individual and group therapy.
Even though there are programs designed to help people in the Somali community it will be difficult to connect with the community as long as they don’t feel any form of connection with the care provider. Providers need to find ways to establish trust with the community and that would allow providers to get their foot into the closed community. Before health care providers could start treatment they first need to establish connection with the community
A few of the different approaches and recommendations that studies have mention are having youth engagement, training programs, specific therapy, cultural sensitivity. Youth engagement programs allows health services to help the community in the long term. Engaging with the youth from a young age allows health services to train and teach the youth about the importance of mental health. Being taught at a young age changes how young adults view mental health and how it could help them in the future. The training program allows people in the community to be trained in order to help others in the community. Training a Somali person gives providers a better chance with having someone in the community work with them or even help interpret and be the middle person between the community and health services. These training programs would be helpful to the community leader such as Imams of the mosque. The Imams play a huge role in the community and building that connections between the health services and community leaders would be beneficial when it comes to connecting with the community.
Based on the research if health care providers were to connect with the Imams of the mosque then they would have a better chance of reaching out to the community. Being that religion is a big part of the culture I believe that health care providers would have a greater opportunity in spreading the importance and understanding of mental health issues and how to deal them. Other places that health care providers could visit in order to connect with the community is at the Somali malls. The Somali malls are usually packed every day and even more on the weekends. Health care providers could visit the community within their own space to help them feel more comfortable rather than attacked and defense. 
Other places that the community gathers is local coffee shops Cedar Riverside, where many Somali people reside. The elders in the community gather around these coffee shops and I believe that if health care providers and trained Somali individuals they could talk with the elders and change their mindset about mental health as well as break the cycle of minimizing mental health that has been passed on through the generations. Visiting the community in the space that if feels comfortable in would make the journey of connecting with the community much easier.
The most common mistake that health care providers make is that they send one of their own into a community and hope to get their message across. It is very rare for a community to greet that individual and accept them immediately. I believe that it is important to have an individual from the community who has the proper training to reach out to the community. In the Somali community it would be easier to send in a trained Somali person in to the community because the community is more likely to accept that person because of the similar background that they come from. They both share similar culture and traditions and above all they speak the same language.
Conclusion
Mental health illness is common within the Somali community because of the traumatic experiences that they have been through escaping the civil war and witnessing the violence that comes with it.  With mental illness being invisible to people, people in the Somali community choose to ignore their symptoms and hope that they are mentally stable. Building awareness in the community helps people to open about their health issues also allowing health care services to help people in the community. It is important for health care providers to understand the different barriers that the community experiences, without being culturally competent, the practitioner could do more harm than good in trying to reach out to Somalis. The community needs to feel understood and supported from health care practitioners because they already feel like outsiders living in a foreign country. With the help of practitioner and people in the community opening up about their mental health issues it allows to reduce the stigma surrounding mental health in the community. Training the youth and individuals in the community not only does it help the community in the present but it also benefits the community in the long term. Teaching the youth at a young age what mental health is and the importance of understanding mental health issues allows them to be aware of their own and others symptoms that they might encounter. Whereas to training individuals from the community such as the elders or leaders of the mosques gives providers a higher chance of connecting with the community and spreading the awareness.
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