Investigating new opportunities to combat stigma in healthcare through a 'universal' approach: Findings from a longitudinal study of healthcare workers in Mombasa, Kenya

Stigma plays a significant role in health and healthcare. To date, anti-stigma efforts have primarily focused on specific individual domains (e.g., mental health, HIV), resulting in fragmented efforts to address many different "stigmas". Theorists now advocate for shifting towards a universal framework to understand and respond to stigma. To empirically test the potential utility of stigma as a universal concept, we analyzed data from 453 healthcare workers participating in a prospective cohort in Mombasa, Kenya. Across four waves comprising 925 points of data (June 2023-December 2024), we found strong correlations between all stigma domains. For example, stigma towards abortion was positively correlated with stigma towards mental health and vice versa (ρ=0.53, 95%CI: 0.47, 0.56). Using structural equation modelling, we tested two models for organizing stigma domains. In the best-fitted model, stigma domains were organized into two thematic categories: conditions & experiences (mental health, abortion, sexual violence, early pregnancy) and behaviors & identities (sex work, drug use, sexual and gender minorities). These two domains were then further organized into stigma as an overarching latent variable, with strong independent associations (β=0.65, 95% CI: 0.57, 0.73 and β=0.61, 95%CI: 0.54, 0.68, respectively). Further, stigma as a latent variable was independently associated with healthcare workers' individual dispositions, including agreeableness (B=-0.19, 95% CI: -0.34, -0.05) and acceptance of others (B=-0.28, 95% CI: -0.39, -0.18). These results support stigma as a 'universal' heuristic among healthcare workers. Anti-stigma interventions should reduce domain-specific activities towards a 'universal precautions' approach targeting larger worldviews, which can improve scalability and resource-efficiency.