Stigma Champion #13, Ann Bagchi: Direct, distract or delegate? Bystander intervention in action
Dr Ann Bagchi
When stigma happens in healthcare, our attention naturally turns to the person experiencing it and the person responsible. But what about everyone else in the room?
Dr Ann Bagchi is a sociologist, family nurse practitioner and an Associate Professor at Rutgers Business School, whose research focuses on stigma and health equity, particularly in HIV. Her Step Up to Stamp Out Stigma (Step Up SOS) intervention explores what people can do when they witness stigma. We spoke to Ann about why people don't always intervene, three practical ways to respond, and why tackling stigma also requires change at an organisational level.
Ann’s key takeaways
Don’t assume someone else will intervene. Diffusion of responsibility is a major barrier to speaking up
Build a toolbox of responses. Different situations call for different approaches
Direct: Address the stigma in the moment when it feels appropriate and safe.
Distract: Interrupt or redirect the situation when direct confrontation isn’t the best option.
Delegate: Bring in someone with the authority to address the behaviour or wider issue.
Support the person experiencing stigma. Your response should help them feel supported, not make the situation worse.
Challenge without shaming. Treat everyone with dignity, including the person whose behaviour you’re challenging.
Recognise that we all make mistakes. Keep learning and be willing to change your own language and behaviour.
Don’t leave change to individual bystanders. Organisations and leaders need to address the conditions that allow stigma to occur.
Listen to people’s experiences. Stigma can stay with people for decades, even when the original encounter is long past
Tell us a little about yourself and how you became interested in stigma in healthcare.
I'm a sociologist by training, and later went back to study as a family nurse practitioner because I wanted to understand the healthcare system better.
My work has always focused on health equity and stigmatised health conditions, particularly serious mental illness and HIV. I'm very much an applied researcher. I'm interested in testing things that might actually work.
What led you to look at bystander intervention?
It came from two pieces of research.
We implemented the People Living with HIV Stigma Index in New Jersey. We didn't see as much recent stigma in healthcare as we expected, but in the open-ended responses people talked about experiences from years earlier. People talked about dentists refusing to treat them, or nurses not bringing food into their hospital room. Those experiences were still affecting people decades later.
We recruited through organisations serving people with HIV, so there's also an important limitation. The people experiencing the most stigma in healthcare might not have been accessing those services at all because they were avoiding them.
We also found that gossip was the type of stigma people reported experiencing most frequently, and the thing they feared the most.
We then did a study with people working in healthcare. We didn't see a lot of stigma on the part of healthcare providers, but we found that 85% of people who had seen stigma happening did nothing to intervene.
Those findings suggested to me that a bystander approach could be useful for addressing stigma and changing the social norms about what's considered acceptable.
I developed a training called Step Up to Stamp Out Stigma, or Step Up SOS. I've mostly been training people working in healthcare, but that's not actually how I originally conceived it.
I wanted people with stigmatised health conditions to lead the training and take it out into communities, and I'd still like to see that happen. Although I do the training specifically on HIV-related stigma, the same approach can be applied to other forms of stigma.
If someone witnesses stigma, what can they actually do?
The training suggests three possible approaches: direct, distract or delegate.
Being direct means saying something in the moment. It might be, "Hey, we don't do that." It doesn't have to be confrontational.
Distracting means interrupting the situation. You might say, "Can you come over here for a minute? There's something I need to talk to you about."
Delegating means appealing to a higher authority.
You can also use a combination of all three.
If someone is being stigmatised, you want to make sure that person feels supported. So in many ways I think being direct is the best approach, but everything depends on the context. You don't want to escalate the situation.
The most important thing is to get the message across that this is not okay.
And eventually you do need to get to delegation because you're not going to change the behaviour unless you change the conditions in which it occurs. Stigma is built into social norms, so people and organisations in positions of power have to be involved if we're going to make a meaningful difference.
What stops someone from intervening when they witness stigma?
There are things like conformity. Nobody else is doing anything, so maybe I shouldn't either.
But a big one is diffusion of responsibility. Everybody assumes somebody else is going to do something or somebody else is going to say something.
There's also fear of making things worse or upsetting someone. And there can be ambiguity. You have to recognise that something is actually stigmatising. If you're thinking, "Hmm, I don't know if that's right or not", that can paralyse you.
It's about building a toolbox of responses.
I'm a very analytical person. If there's an issue going on, I like to sit there and think, "What does the data say?" That's great, but if the house is on fire, I don't want to be sitting there thinking, "Huh, wonder how that fire started?"
We need to learn which responses are appropriate in different situations and develop the skills we might be weaker in, whether that's diplomacy or knowing how to defuse a situation.
How can we challenge stigma without shaming the person responsible?
I think it comes down to treating everyone with dignity.
Even people who we think have said or done something stigmatising deserve to be treated with some degree of dignity. If you can help people save face without trying to shame them, I think that can be more effective.
And everybody makes mistakes. We all need to continue to educate ourselves.
I found that out myself. I was developing some slides about HIV stigma and went looking for a resource about language. One of the phrases it identified as stigmatising was “people living with HIV”, which I'd been using for years as a researcher.
The guidance recommended “people with HIV” instead. We don't generally say someone is “living with diabetes”, for example. We say they are a person with diabetes.
Here I was educating other people about stigma and discovering that I was using language that could itself be considered stigmatising.
Something else I've learned is the importance of validation. If I say, "I know you were trying to do X, Y, Z, but..." I've just invalidated what I said before it.
Instead, I can say, "I know you're doing your best, and this is a better way of doing it."
Something as small as changing but to and can make a difference to how someone responds when you're trying to correct them.
What can organisations do to support bystander intervention without putting all the responsibility on individual healthcare workers?
That's one of the biggest benefits of approaching stigma as a structural issue.
Individuals still have a role. They have to be willing to speak up when they see stigma happening. But they shouldn't have to do that alone.
Stigma is about social norms. That's the heart of stigma: what's considered normal and what's not, and the judgements that go along with that.
Organisations and people in positions of power have a lot of influence over those norms. So if you want to change the behaviour, you also have to change the conditions in which that behaviour occurs.
That's why it's important to get the higher-ups and decision-makers involved. Otherwise, you're putting the onus back on individual healthcare workers rather than changing the system around them.
What do healthcare professionals need to understand about stigma before they can change it?
The biggest thing is making people aware of what stigma actually looks like. If people don't recognise something as stigmatising, they're going to continue to do it.
Years ago, I went to see my physician and had a stack of papers with me about stigma. He asked what I was reading and when I told him, he said, "So are you for it or against it?"
I said, "What do you mean?"
He told me that he liked to use shame, to try to get people to change their behaviour. I said, "I don't think shaming people is a way to motivate them."
That mindset, that stigma is some kind of tool you can use to motivate people, has got to change.
But sometimes the stigma is less obvious. I've also been working on increasing routine HIV screening in primary care. I once interviewed a primary care provider who told me she'd worried that if she offered someone an HIV test, they might be offended.
Then she realised: "The stigma was with me."
Years later, another physician I worked with said almost exactly the same thing. At the beginning of our study, she was screening about 2% of her patients for HIV. Nine months later, she was screening around 67%.
She had assumed patients would feel stigmatised by being offered the test. But the more you do HIV testing as part of routine screening, the less stigmatising it's going to be. It's just another thing you're screening for.
You’ve worked across countries and different areas of healthcare. What have you learned about tackling stigma?
To me, it's all about empathy. This idea of treating empathy as a weakness is just wrong.
Everybody wants to feel dignified. So many of the problems in our world are caused by the fact that we aren't treating people with the dignity, respect and empathy that every person deserves.
If we start from that, we can make things better for everyone.
If you had five minutes with a healthcare leader or policymaker, what would you want them to understand?
It goes back to treating people with respect and thinking about what's for the greater good.
There's this idea of "deservedness": who deserves to get help?
I feel like there are people who would rather tear down an entire system than let one person who they think doesn't deserve something get it.
We need more kindness and more consideration.
If we spoke again in five or ten years, what would you hope had changed?
I would hope that people truly feel heard in the healthcare system. That we actually listen to what people are telling us rather than dismissing their experiences.
And I hope we continue to educate ourselves. We're going to make mistakes, but having the empathy and humility to acknowledge those mistakes goes such a long way.
We're probably not going to eliminate stigma anytime soon, but we can minimise its impact.
I think back to people in our Stigma Index research who talked about experiences they'd had when they were diagnosed with HIV 20 or 25 years earlier. Those experiences were still affecting them decades later.
It still hurts their soul.
Addressing stigma to help minimise the likelihood of someone having to experience that type of pain can go such a long way.