BACKGROUND Researchers have long recognized that stigma is a global, multi-level phenomenon requiring intervention approaches that target multiple levels including individual, interpersonal, community, and structural levels. While existing interventions have produced modest reductions in stigma, their full reach and impact remain limited by a nearly exclusive focus targeting only one level of analysis. METHODS We conducted the first systematic review of original research on multi-level stigma-reduction interventions. We used the following eligibility criteria for inclusion: (1) peer-reviewed, (2) contained original research, (3) published prior to initiation of search on November 30, 2017, (4) evaluated interventions that operated on more than one level, and (5) examined stigma as an outcome. We stratified and analyzed articles by several domains, including whether the research was conducted in a low-, middle-, or high-income country. RESULTS Twenty-four articles met the inclusion criteria. The articles included a range of countries (low, middle, and high income), stigmatized conditions/populations (e.g., HIV, mental health, leprosy), intervention targets (e.g., people living with a stigmatized condition, health care workers, family, and community members), and stigma reduction strategies (e.g., contact, social marketing, counseling, faith, problem solving), with most using education-based approaches. A total of 12 (50%) articles examined community-level interventions alongside interpersonal and/or intrapersonal levels, but only 1 (4%) combined a structural-level intervention with another level. Of the 24 studies, only 6 (25%) were randomized controlled trials. While most studies (17 of 24) reported statistically significant declines in at least one measure of stigma, fewer than half reported measures of practical significance (i.e., effect size); those that were reported varied widely in magnitude and were typically in the small-to-moderate range. CONCLUSIONS While there has been progress over the past decade in the development and evaluation of multi-level stigma interventions, much work remains to strengthen and expand this approach. We highlight several opportunities for new research and program development.

中文翻译：

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多层次污名干预的系统综述：科学现状和未来方向。

背景技术研究人员早已认识到，污名是一种全球性的，多层次的现象，需要采取针对包括个人，人际交往，社区和结构等多个层面的干预方法。尽管现有的干预措施已使耻辱感有所减少，但它们的全部影响力和影响力仍然受到几乎仅针对一个分析水平的几乎排他性关注的限制。方法我们对减少多级耻辱减少干预措施的原始研究进行了首次系统综述。我们使用以下资格标准进行纳入：（1）同行评审，（2）包含原创研究，（3）在2017年11月30日开始搜索之前发表，（4）评估了超过一个级别的干预措施（5）将污名作为结果。我们从多个领域对文章进行了分层和分析，包括研究是在低收入，中等收入还是高收入国家进行的。结果24篇文章符合纳入标准。文章涵盖了多个国家/地区（低收入，中等收入和高收入），被污名化的疾病/人群（例如，艾滋病毒，精神健康，麻风病），干预目标（例如，被污名化的人群，医护人员，家庭，和社区成员），以及减少耻辱感的策略（例如，联系，社交营销，咨询，信仰，解决问题），大多数使用基于教育的方法。共有12篇（50％）文章检查了社区层面的干预措施以及人际和/或个人内部层面的干预措施，但只有1篇（4％）将结构层面的干预措施与另一层面进行了结合。在24项研究中，只有6项（25％）是随机对照试验。尽管大多数研究（24个研究中的17个）报告了至少一种污名的统计学上显着的下降，但少于一半的报告具有实际意义（即效果大小）的测量。那些被报道的数量级差异很大，通常在中小范围内。结论尽管在过去的十年中，多层次耻辱干预措施的开发和评估取得了进展，但仍需要大量工作来加强和扩展这种方法。我们重点介绍了一些新研究和计划开发的机会。结论尽管在过去的十年中，多层次耻辱干预措施的开发和评估取得了进展，但仍需要大量工作来加强和扩展这种方法。我们重点介绍了一些新研究和计划开发的机会。结论尽管在过去的十年中，多层次耻辱干预措施的开发和评估取得了进展，但仍需要大量工作来加强和扩展这种方法。我们重点介绍了一些新研究和计划开发的机会。