# The association between expectations of stigma and experiences of structural stigma in healthcare encounters among a cross-section of Canadians living with a mental illness or substance use disorder

## TL;DR

This study explores how expectations of stigma among Canadians with mental illness or substance use disorders relate to their experiences of stigma in healthcare settings.

## Contribution

The study reveals that higher expectations of stigma are unexpectedly linked to fewer experiences of structural stigma in healthcare, particularly among males.

## Key findings

- Higher expectations of stigma were associated with decreased experiences of structural stigma in healthcare encounters.
- The association was significant among males and in three out of four tested models.
- Expectations of stigma related to substance use disorders were linked to stigma experiences in both mental and physical healthcare visits.

## Abstract

People living with mental illnesses or substance use disorders often anticipate being devalued or discriminated against by others (anticipatory stigma). These expectations can lead to heightened sensitivity to social rejection, hypervigilance, and overreactions to perceived threats. Healthcare settings are a common context for structural stigma, where negative organizational cultures and provider behaviours can compromise patient-provider interactions and quality of care, contributing to poorer health outcomes. Grounded in Modified labelling theory, this study examined whether higher expectations of stigma were associated with greater self-reported experiences of structural stigma during healthcare encounters. Data were drawn from a 2022 national sample of Canadians 18 years and older who reported a healthcare visit within the recall period (analytic n = 1509). Expectations of stigma and experiences of structural stigma in healthcare settings were measured using the Perceived Devaluation and Discrimination Scale and the Stigma Cultures in Healthcare Scale, respectively. Contrary to our hypotheses, experiences of structural stigma decreased as expectations of stigma increased. This association was only significant among males and in three out of the four models tested. Expectations of stigma related to a mental illness were associated with experiences of stigma during mental healthcare visits, and expectations of stigma related to a substance use disorder were associated with experiences of stigma during both mental and physical healthcare visits, controlling for the effects of age and estrangement from family and friends. These findings suggest that protective coping strategies, selective engagement with healthcare, and expectancy effects may shape the relationship between anticipated and experienced stigma, highlighting the complex interplay between individual psychological predispositions and structural healthcare environments.