Structural Stigma in Health-Care Contexts for People with Mental Health and Substance Use Issues – A Literature Review

People living with mental health and substance use issues need prompt access to quality health care. Sometimes they receive it, but often they do not. Significant barriers stand in the way when people with lived experience seek access to care, with many challenges worsened further still by stigma. Even when people living with mental health and substance use issues do gain access, they are more likely than others to receive an inferior quality of health-care services.

Systematic problems with accessing and receiving quality health care severely compromise the health and well-being of people living with mental health and substance use issues. This experience also increases the chance that they will acquire other health conditions, have their illnesses go untreated, and experience health-related crises. It also reduces their longevity — people with lived experience die 10 to 25 years earlier than people who do not have to face these challenges.

The health-care system is consistently identified as a major contributor to health disparities among people living with mental health and substance use issues. Scholars have illustrated how the health-care system participates in the production of structural stigma: the ways it produces inequities and injustices for people living with mental health and substance use issues. The policies of health-care institutions and the practices of health-care practitioners can systematically deprive their right to quality health care.

This report provides a review of the research and literature pertaining to structural stigma in health-care contexts, including how it affects people living with mental health and substance use issues, how it is expressed in the health-care system, and how it can be reduced.

Broadly speaking, the literature on structural stigma in health-care contexts focuses on two key issues: access and quality. Structural stigma surfaces when policies and practices produce inequitable access to health care for people living with mental health and substance use issues. This access is compromised in several ways: through the inequitable distribution of resources, the undertreatment of health problems, the withholding of services, and the fragmented care. Structural stigma is also expressed when people systematically receive a lower quality of care. The serious issues impinging on quality of care include negative attitudes and poor practices among health-care practitioners, adverse health-care interactions and experiences, and the overuse of coercive or paternalistic approaches.

A comprehensive strategy for addressing structural stigma in health-care contexts for people with lived experience include a combination of approaches that seek to:

1. improve the attitudes and practices of health-care practitioners and others (e.g., trainees, decision makers),
2. strengthen the integration and coordination of care,
3. achieve parity for mental health and substance use issues,
4. expand access to effective treatment,
5. establish mechanisms to monitor structural stigma,
6. foster the inclusion and participation of people living with mental health and substance use issues, and
7. enhance and enforce protections for people with lived experience.