Stigma, Health and Well-Being

In order to understand the phenomenon of stigma in different populations (e.g., different ethnicities, different diseases, and different conditions), this Special Issue collects papers from around the world to illustrate the stigma phenomenon. After a rigorous process of peer review, a total of 24 papers were published and included in the Special Issue. These papers were contributed from different continents and countries, including the Americas (e.g., United States), Europe (e.g., Finland), and Asia (e.g., Saudi Arabia). Therefore, the diversity of ethnicity was ensured in the Special Issue. Moreover, these papers address different stigmatized populations/conditions (e.g., mental illness, obesity, public housing, homosexuality, and transgender). The most discussed populations were those with mental illness and those with obesity/overweight. However, additional evidence on the stigma topic is still needed. Specifically, future studies could consider the following directions to explore in depth the issues of stigma in different populations: (1) using longitudinal designs to understand the temporal or causal relationship between stigma and other related psychosocial factors; (2) designing treatment programs to fight stigma—this could be carried out in healthcare providers, healthcare trainees, the public, caregivers, and the stigmatized populations.


Introduction
Although the modern world has enhanced the quality of healthcare and increased the successful rate of treatment due to the health technologies and available medications available, some psychosocial issues related to diseases remain unresolved. Indeed, the literature shows that populations with different disabilities have increased life expectancy [1,2]; however, their psychosocial health seems not to be well taken care of in our communities.
Among these psychosocial health issues, stigma seems to be one of the most important issues that should be tackled to avoid its tremendous and negative impacts on health promotion [3]. According to the literature, stigma can be conceptualized as the co-occurrence of the following: (i) labeling and distinguishing differences; (ii) stereotyping the individuals who are stigmatized as different in a negative way; (iii) separating the individual according to the labeling (i.e., differentiating people who are labeled from those who are not (e.g., using the term of "us" for unlabeled individuals and "them" for labeled individuals)); (iv) having negative emotional reactions (e.g., anger and fear) toward the individuals who are stigmatized or labeled; (v) discriminating the group which is labeled and letting the labeled group experience status loss, and (vi) unfolding the aforementioned processes via economic, social, and political ways to decrease the power of the labeled population [4,5]. Accordingly, a variety of forms and types of stigma have been proposed: public stigma, experienced stigma, perceived stigma, and self-stigma (i.e., internalized stigma) [6]. Ample literature also shows that any type of stigma poses a great threat to well-being and health through different routes (e.g., lost opportunities in treatment availability, employment, education, and living) for those who are stigmatized [3,[6][7][8]. Therefore, the individuals who are stigmatized are at high risk of having low quality of life. In order to resolve the complex issues of stigma, the link between stigma and health should be substantially investigated. More evidence is thus needed to assist healthcare providers who work in the field in understanding the stigma issue among populations worldwide.

The Aims and Contributions of the Special Issue
In this Special Issue, we intend to address the knowledge gap in the understanding of stigma and how it relates to different aspects of health outcomes across different populations. Therefore, we have invited international submissions of papers and report the state-of-art information on stigma issues. We are glad that a total of 24 original papers have been peer reviewed and published in the Special Issue. The aims of the Special Issue are fully addressed by the contributed papers. Specifically, the papers include diverse populations in ethnicity (e.g., Caucasians, Vietnams, Taiwanese, Korean, Hong Kong people, and Saudi Arabian), disability (e.g., physical disability and mental health problems), conditions (e.g., transgender, weight problems, and caregiving), and human developmental stages (e.g., adolescence and young adults). Detailed information of the contributions can be found in the following section (i.e., 3. Findings of the Contributions in the Special Issue). Therefore, we are confident that the collection of the Special Issue achieves our original intention of filling the literature gap on stigma.

Stigma on Obesity
The findings of the contributions in the Special Issue are summarized in Table 1. Lipowska et al. [9] compared the perceived stigma between university students from Poland and those from Vietnam to illustrate the cultural differences in body stigma. Their findings indicate that Confucian concepts of modesty and shame may impact university students' concern about their bodies; therefore, university students from Vietnam were more vulnerable than those from Poland to criticisms of their bodies. Similar to the body shape issue, Lin et al. [10] assessed two types of weight stigma (perceived weight stigma and weight-related self-stigma) in 464 junior high school students in Taiwan. Their findings indicate that adolescents with overweight using a self-reported body mass index had higher levels of perceived weight stigma and self-stigma but not public stigma; similar findings were revealed in adolescents with self-perceived overweight versus those with self-perceived non-overweight. In addition, Lin et al. [10] found that higher levels of perceived weight stigma were associated with higher levels of anxiety among adolescents with overweight regardless of whether this was actual or self-perceived.
Fung et al. [11] incorporated the weight-related self-stigma concepts into the well-known Theory of Planned Behavior model among Hong Kong university students. With the satisfactory model fit in the structural equation modeling, they found that higher levels of weight-related self-stigma were associated with lower levels of physical activity among university students who were overweight (n = 104). However, such negative association was not observed among those who were not overweight (n = 221). In addition to the finding regarding the association between weight-related self-stigma and healthy behaviors, an association between experienced weight stigma and unhealthy behaviors has been found. Wu et al. [12] recruited 166 Asian Americans, with most of them being the first generation to understand the association between experienced weight stigma and binge eating behaviors. The participants were defined as overweight according to the body mass index cutoff for Asians (i.e., body mass index > 23 kg/m 2 ). After controlling the effects of racism and general stress, Wu et al. [12] concluded that experienced weight stigma is an independent factor associated with binge eating behaviors for those who may have a weight problem. The female sample with sexual minority had high rates of experienced weight stigma. In addition, they frequently reported co-occurrence of perceived and experienced weight stigma because of their marginalized identities.    The association between discrimination and stress was lower in those living in social-mix housing complexes than in those living in independent public housing complexes.
Panza et al. [13] additionally studied weight stigma in a special population of sexual minority women with overweight/obesity (i.e., body mass index over 25 kg/m 2 ) in the United States. Although their sample size was relatively small, high rates of experienced weight were observed among this sample. In addition, their identity of sexual minority was co-occurrent with their perceived and experienced weight stigma. Therefore, studies with a large size are needed to deeply understand this situation for sexual minority women.

Stigma on Mental Illness
In addition to obesity, mental illness (including anxiety, attention-deficit/hyperactivity disorder (ADHD), autism spectrum (ASD), dementia, and depression) is another disease/condition that is largely studied with stigma. Luís et al. [14] investigated 214 male adults having a heterosexual relationship with a reproductive-age partner who were suffering from postpartum mood and anxiety disorder in Coimbra. They applied structural equation modeling to quantify the association between stigma (possibly self-stigma) and intentions to recommend professional help-seeking. Their results indicate that the male adults with higher levels of (self-)stigma had lower intentions to recommend professional help-seeking to their partners.
Rodríguez-Almagro et al. [15] used a mixed-methods study to understand nursing students' attitudes toward mental illness in Spain. Through data from 359 (quantitative study) and 30 (qualitative study) nursing students, associations between lowered public stigma and elevated positive attitude toward people with mental illness were found. Additionally, nursing students who were in a higher year of study (especially third year or above) had lower levels of public stigma than those who were in a lower year of study. Riffel and Chen [16] also studied the students' attitudes toward mental illness. However, Riffel and Chen [16] investigated more than nursing students and they only used a qualitative design to understand students' attitudes. Through semi-structured interview and a qualitative description method, 18 students from nine health programs in a Canadian University revealed their attitudes toward mental illness. The findings indicate that most students had good knowledge of mental health and they showed positive behaviors when interacting with people with mental illness. However, stigmatizing attitudes and unpreparedness to work with people with mental illness were observed in some students.
Chang et al. [17] recruited 400 caregivers who were taking care of a child diagnosed with attention-deficit/hyperactivity disorder (ADHD) in Taiwan. Their findings indicated that caregivers' affiliate stigma is a significant factor associated with their unfarmable attitudes toward the ADHD diagnosis and related treatments. In addition, the aforementioned association was not moderated or confounded by sociodemographic factors and ADHD symptoms. Ng et al. [18] recruited 63 parents who had a preschool child diagnosed with autism spectrum disorder (ASD) in Hong Kong. They investigated the affiliate stigma among the parents and their children's participations. Their findings indicated that parents having a preschool child with ASD had relatively high level of affiliate stigma. However, higher levels of affiliate stigma were not associated with most of the children's participation. The negative association between parents' affiliate stigma and children's participation was only found in the community activities.
The affiliate stigma has also been studied in older populations. Su and Chang [19] assessed affiliate stigma and related psychological factors among family caregivers of people with dementia (n = 270) in Taiwan. Their findings indicate that affiliate stigma is associated with the psychological factors of anxiety and caregiving burden but not depression. In addition, male caregivers were found to have a higher level of affiliate stigma than their female counterparts.
Lee et al. [20] assessed two types of stigma (public stigma and self-stigma) among 184 nurses who were at risk of depression in Korea. They found that public stigma, self-stigma, and depression are negatively associated with help-seeking behaviors. Moreover, self-stigma and depression were found to be significant mediators in the relationship between public stigma and seeking psychiatric help for depression problems. Therefore, they concluded the importance of regularly assessing self-stigma and depression levels among registered nurses.
Hanlon and Swords [21] invited 242 adolescents in Ireland to read a vignette describing a character (either a male (Sean) or a female (Katie)) with the problems of generalized anxiety disorder. Then, Hanlon and Swords [21] assessed the factors of stereotype, prejudice, discrimination, and help-giving intentions among these adolescents. They found that the endorsement of the stereotype of "weak-not-sick (i.e., the features of generalized anxiety disorder)" was associated with higher prejudice, stronger discrimination, and weaker intentions to help.
Ma and Hsieh [22] designed an anti-stigma course using a course framework (i.e., proceeding from knowledge to experience; then, action) to examine whether the anti-stigma course decreased the public stigma among occupational therapy students in Taiwan (n = 16). The outcome measures to assess the effectiveness of the anti-stigma course included two types of public stigma (discrimination through Social Distance Scale and attitudes through Stigmatizing Attitudes Toward Mental Illness). They found that the anti-stigma course had the effect of decreasing public stigma for the occupational students and such effects could last a year.
Mahsoon et al. [23] used a cross-sectional design to understand how young adults in Saudi Arabia (n = 236) view the disease of mental illness and those with mental illness. Their results indicated that young adults in general had negative attitudes toward both the illness and people suffering from mental illness. In addition, beliefs toward mental illness, perceived parental support, and mental help-seeking attitudes were not associated in their study findings. Another Saudi Arabia study was a qualitative study on affiliate stigma. Specifically, Sharif et al. [24] utilized a qualitative study design with semi-structured interviews to assess affiliate stigma among family caregivers of people with mental illness (n = 13) in Saudi Arabia. They found that different types of burden experienced by the caregivers were highly needed after conducting the thematic analysis. Moreover, misconceptions about mental illness were found to be harmful for the caregivers and thus correcting such misconceptions is an important topic.
Paananen et al. [25] used a qualitative study with a large sample size (n = 624 from mental health professionals and n = 300 dyads from mental health rehabilitants and their family members) to investigate the evaluation and rationale of stigma prevalence in mental health professionals and rehabilitants from the clubhouses in Finland. Through inductive content analysis, they found that perceived stigma is a phenomenon experienced by most of the rehabilitants. Ko et al. [26] used an online survey to assess the perceived stigma toward people who are homosexual and involved in same-sex marriage in two important time points in Taiwan: 23 months before the same-sex marriage referendum (Wave 1) and 2 months after the referendum (Wave 2). Among the non-heterosexual individuals (n = 798 in Wave 1 and 539 in Wave 2), their perceived unfavorable attitudes were associated with their suicidal ideation. Among heterosexual individuals (n = 1796 in Wave 1 and 1443 in Wave 2), those who were friendly with homosexual individuals (or supported the referendum) had the same association found in the non-heterosexual individuals (i.e., the perceived unfavorable attitudes toward homosexuality and same-sex marriage were associated with suicidal ideation). Similar to the context of homosexuality, Ozamiz-Etxebarria et al. [27] investigated the public stigma toward transgender people among university students in Spain. In general, the university students had relatively positive attitudes toward transgender people and this may be due to their higher education training. Nevertheless, the university students' knowledge of transgender identity was not satisfactory. Therefore, Ozamiz-Etxebarria et al. [27] recommend the need to expand transgender education in the university environment.
Silván-Ferrero et al. [28] invited 289 people with disabilities to participate in an online survey in Spain. The participants had different levels of disability, including those obtaining a Disability Certificate to access some benefits and those were qualified for non-contributory pension. Silván-Ferrero et al. [28] proposed a mediational path analysis and found that the association between higher levels of self-stigma and lower levels of quality of life among the participants with physical disability was mediated via resilience. Lewis et al. [29] utilized a qualitative design to understand the self-stigma of smoking among parents who had child(ren) at home in Scotland. Through thematic analysis, Lewis et al. [29] observed that parents may be afraid of disclosing their smoking habits in their societies because of their smoking self-stigma. Therefore, parents may perform hidden smoking and are not confident enough to stop smoking.
Lin et al. [30] treated solitude as a type of situation related to self-stigma and explored its relationship with physical and mental health among 562 junior college students in Taiwan. They found that the solitude capacity score was associated with physical and mental health. Therefore, they concluded that adolescents have better physical and mental health if they can cope with the self-stigma resulting from loneliness. Stelzmann et al. [31] used a qualitative study to investigate how healthcare providers in Germany view the media coverage of pedophilia. The healthcare providers included psychologists and medical doctors. In the semi-structured interview, both positive and negative attitudes toward the media coverage of pedophilia were found. The authors thus concluded that journalists may need to have a facto box to destigmatize pedophilia and increase the benefits of child sexual abuse prevention. Jun and Han [32] analyzed the data from the 2017 Seoul Public Housing Residents Panel Survey to investigate the experienced stigma issues among people who were living in public housing. They found that the association between discrimination and stress was lower in those living in social-mix housing complexes than in those living in independent public housing complexes.

Conclusions and Future Directions
In conclusion, the importance of tackling stigma has been illustrated in a variety of populations. However, there is still a literature gap in the realm of stigma. Therefore, future studies are warranted to further explore and investigate this topic. Specifically, (1) the collected papers in the Special Issue used a cross-sectional design to investigate the phenomenon of stigma regardless of the type of stigma; (2) a number of papers in the Special Issue adopted a qualitative design to investigate the stigma phenomenon, which needs following quantitative evidence to support; (3) only one study examined the treatment effects on anti-stigmatization. Therefore, future studies could consider the following directions to explore in depth the issues of stigma in different populations: (1) using longitudinal designs to understand the temporal or causal relationship between stigma and other related psychosocial factors; (2) designing treatment programs to fight stigma-this could be carried out in healthcare providers, healthcare trainees, the public, caregivers, and stigmatized populations.