Policies Can Embed Stigma in Healthcare, Review Maps How to Fix Them

Structural stigma against people with mental health conditions is not only written into the attitudes of individual clinicians but also into the policies, protocols, and procedures of healthcare organizations themselves.

The review’s starting point is a striking gap. When the researchers initially searched six academic databases alongside grey literature, asking what tools or guidelines currently exist to review policy through an anti-stigma lens, they found none. That absence prompted a pivot: rather than reviewing existing tools, the team reframed the question to ask what such a tool should look like. Repeating their search with the revised question, they identified 81 papers, composed of 69 peer-reviewed articles and 12 grey literature sources, and coded the findings according to the three commonly recognized stages of the policy cycle: development, implementation, and evaluation.

Structural stigma, as the authors frame it, refers to the societal-level barriers, policies, and practices that lead to the marginalization and discrimination of certain groups. Within a multilevel framework, it is not a separate or downstream phenomenon but forms the broader context in which public stigma and self-stigma emerge and are maintained, while also being reinforced through those processes. A recent literature review on structural stigma in healthcare classified the harms into two broad categories: inequitable access to healthcare, including under-resourced services, lack of cost coverage, patients being deprioritized or denied care, and the artificial systemic separation of mental health, substance use, and physical healthcare; and poor quality of healthcare, encompassing negative provider attitudes, adverse interactions, and coercive or punitive approaches such as forced medication and involuntary hospitalization.

The emergency department emerges as a setting where these harms are particularly evident. In an earlier phase of the EMBER Project, Smith and colleagues conducted interviews and focus groups with patients, their friends and family, and ED staff, and found that structural stigma was a major theme. Participants described psychiatric spaces as being like jail cells, and policies and standards contributed to limited inpatient bed availability, which in turn results in prolonged ED boarding for people with lived and living experience of mental health conditions. A study in Calgary, Alberta, reviewing 200 charts of patients admitted from the ED to psychiatric services, found that the average boarding time was 23.5 hours, and adverse experiences were associated with longer boarding times. A Canadian study found clinically significant differences in boarding between admitted mental health patients and non-mental health patients, at 52.6 hours versus 29.3 hours, despite the Canadian Association of Emergency Physicians recommending that 90 percent of admissions to inpatient units from the ED occur within 8 hours.

Across all phases of the policy cycle, the review identified two overarching considerations: inclusion and intersectionality. Policy development has largely been conducted by those considered experts, neglecting the opinions and experiences of those most impacted by the policies. The authors stress that involving people with lived and living experience must be done carefully to avoid tokenism, which they define as the practice of making perfunctory or symbolic efforts to engage communities or patients. A qualitative meta-synthesis on participation in mental healthcare found tokenism was a central theme in almost half of the studies included in that review. Intersectionality, meanwhile, emphasizes how social identities interact to create unique and multifaceted experiences of discrimination and privilege, and the review argues that policies must address not only the singular stigma associated with mental health conditions but also the compounding effects of various stigmatized identities.

Within the policy development phase, the review highlights three key considerations. The first is co-creation, an inclusive approach in which diverse groups engage in dialogue and direct interaction to address complex problems, equalizing decision-making power among participants. Involvement of people with lived and living experience should begin in the early stages of policy development and continue into decision-making about the final product, with roles explicitly set out in a transparent manner, defined expected outcomes, and proper compensation and payment. The second consideration is language: stigmatizing terms such as substance abuser, non-compliant, aggressive, abnormal, mentally ill, and schizophrenic can be perceived as problematic and hurtful, and have been shown to affect healthcare providers’ attitudes. The authors note there is no single term that universally reduces stigma, so policymakers should recognize trade-offs and align terminology with communication goals, and, importantly, ask people with lived experience what their preferred terms are. The third consideration is quality of care, framed as a healthcare equity issue, with policy development urged to advocate for equitable care and to be informed by the existing literature on emergency care of psychiatric patients.

For the implementation phase, the review organizes findings using a four-stage framework of exploration, adoption, active implementation, and sustainment. In the exploration stage, education and awareness initiatives that help providers recognize how structural stigma manifests during care processes are likely crucial. In the adoption stage, clear and transparent communication, free of technical and stigmatizing language, ensures policies are understood by policymakers, healthcare providers, people with lived experience, and the public alike. In the active implementation stage, the authors point to a particular risk in urgent, time-sensitive settings: policies often lack precision, leaving discretionary space in which structural stigma can increase the potential for bias, particularly in situations characterized by uncertainty, ambiguity, and complexity. Policies must therefore be specific and detailed enough to minimize interpretation, supported by tools and training illustrating how to apply them across a variety of clinical scenarios. In the maintenance stage, funding constraints, logistical challenges, and a lack of motivation threaten sustainability, and the authors recommend securing dedicated funding, integrating anti-stigma policies into existing procedures, and establishing reward programs that incentivize anti-stigma initiatives.

The evaluation phase presents its own formidable challenges. The literature frequently cited a lack of clear strategies for evaluating policy outcomes, and methodological challenges to producing evidence on policy outcomes were described as a significant barrier to mobilizing policy actions for health equities. Difficulties include combining multiple data sources, reliance on secondary data with the potential for selection bias, problems of attribution linking outcomes to a specific policy, unobserved variables, and time lags between implementation and observable effects. Stigma itself is difficult to define and measure, spanning knowledge, attitudes, and behaviours of both those stigmatized and those in positions of power. The review recommends conceptualizing policy as an intervention, examining impacts across multiple levels and time points, planning evaluation from the outset rather than as an afterthought, and including the community affected by the policy in the evaluation process. It also cautions that anti-stigma interventions can sometimes have unintended consequences, including exacerbating stigma or worsening internalized stigma, so evaluations must critically explore what harms may have been unintentionally caused. As a promising measurement development, the Mental Health Commission of Canada is working on validated stigma scales; the Stigma Cultures in Healthcare Scale, a 23-item measure developed from qualitative research with people with lived experience of accessing healthcare services, showed high reliability in a pilot analysis of more than 2400 people across Canada.

The authors are candid about the limits of the evidence base. While the research literature suggests policy is a potential target for reducing structural stigma, there is little empirical evidence about how to achieve this effectively, and relatively few studies have used policy creation or modification and demonstrated a reduction in structural stigma. The lack of outcome research makes it harder to advocate for such interventions, especially given the limited resources and capacity of many healthcare settings. The review also emphasizes that policy action should complement, not replace, interpersonal-level interventions such as anti-stigma training for healthcare providers, since combining structural and individual-level interventions has been found to more effectively mitigate stigma, though research examining such holistic approaches remains limited.

What the paper ultimately delivers is a methodological foundation rather than a finished tool. The authors intend these evidence-informed recommendations to shape a future policy review tool that would be flexible, adaptable, and user-friendly enough for complex, fast-paced healthcare settings, with the goal of improved access, quality of care, and health equity for people with lived and living experience of mental health conditions. They suggest an incremental approach may be necessary in settings with limited capacity, and they note that the considerations could extend beyond hospital policy to broader contexts, including laws, regulations, and system-wide principles, as well as to program development and organizational settings outside healthcare. Most importantly, they argue, people with lived and living experience must be included as co-creators throughout the work for the field to effect meaningful change and reduce the negative impacts of stigma.

Subject of Research: Anti-stigma considerations for healthcare policy development, implementation, and evaluation to reduce structural stigma related to mental health conditions

Article Title: Examining policy development, implementation, and evaluation through an anti-stigma lens to reduce structural stigma related to mental health conditions in healthcare settings

Article References: Henderson, L., Giglio, E., Chen, S. X., Grimminck, R., & Szeto, A. C. H. (2026). Examining policy development, implementation, and evaluation through an anti-stigma lens to reduce structural stigma related to mental health conditions in healthcare settings. Discover Health Systems, 5(1), Article 78. https://doi.org/10.1007/s44250-026-00421-z

Image Credits: AI Generated

DOI: 10.1007/s44250-026-00421-z

Keywords: structural stigma, mental health, healthcare policy, emergency department, policy cycle, co-creation, narrative review, trauma-informed care, health equity, policy evaluation, stigma reduction, EMBER Project