A systems model of the factors reinforcing sexual and reproductive health provider stigma: practical implications for interventions

Stigma in sexual and reproductive healthcare (SRH) is a barrier to optimal patient experience and perpetuates healthcare disparities. The underlying causes of stigma may be embedded in the dynamic social, ecological, and environmental factors associated within multiple levels of the health system. Given this, linear and unidimensional approaches to understanding SRH stigma are insufficient. In contrast, applying a systems lens in concert with the social ecological model of public health can uncover root causes of stigmatising behaviours among SRH providers, and identify critical leverage points for programmatic intervention. In this qualitative study, SRH providers were interviewed to identify the factors contributing to stigma and their interconnectedness. A two- phase analytic approach was adopted. First, provider-identified SRH stigma factors were identified and categorised using the social ecological model. Then, connections between variables were identified, resulting in a systems model with two significant feedback loops. The model and feedback loops highlight the importance of provider characteristics in reducing SRH stigma including capacity to tolerate imperfection, and humility, curiosity, and self-reflection. Findings indicate areas for potential intervention to reduce SRH stigma and enhance the equitable delivery of SRH services.