Stigma is a common and recurring feature of infectious disease outbreaks. It can be defined as the social devaluation and exclusion of individuals or groups based on perceived association with a discrediting illness (1, 2). The sources of outbreak-related stigma are multifaceted. It often stems from fear and uncertainty surrounding a novel disease or moralisation of the illness, resulting in blame being placed on certain individuals or groups for disease transmission (1). Outbreak control measures, such as surveillance or quarantine, can also inadvertently reinforce stigma, particularly when they are intrusive or restrict personal freedoms (1). Similarly, public health messaging that is alarmist or over-emphasises preventability through basic hygiene may exacerbate stigma.

The detrimental impact of stigma on both physical and psychosocial wellbeing is well-described (3). Individuals stigmatised during outbreaks may experience psychological distress, depression, and a reluctance to seek medical care, thereby compounding their vulnerability (4–6). Furthermore, stigma may undermine critical public health measures by discouraging community cooperation with outbreak response efforts, fostering distrust towards health authorities, and lowering adherence to preventive behaviours (1).

Existing systematic reviews have primarily examined stigma interventions in established infectious diseases such as HIV, tuberculosis, or leprosy. However, outbreaks present distinct challenges for stigma mitigation. These events tend to arise suddenly, progress rapidly, and occur within diverse sociocultural settings, complicating the design, implementation, and evaluation of interventions (7, 8). While these distinctions limit the transferability of evidence from non-outbreak infectious disease contexts, commonalities in stigma across outbreaks points to the potential for adaptable, cross-outbreak learnings (9).

Although the importance of addressing stigma during outbreaks is increasingly recognised, evidence on how best to reduce it remains limited. A clearer understanding of which outbreak-specific approaches have been evaluated, and with what results, is therefore critical to strengthening preparedness and response.

This systematic review identifies and synthesises evidence from studies evaluating outbreak-related stigma reduction interventions. By mapping the available evidence and assessing the effectiveness and methodological quality of these studies, the review aims to inform public health preparedness strategies and support the development of stigma-sensitive approaches to outbreak response.

The protocol for this review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD420251007553). The review has been reported in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (10).

The search identified 4,148 unique records, of which 76 were retrieved for full-text review (Figure 1). An additional 15 potentially relevant studies were identified through reference list screening, one of which fulfilled the eligibility criteria. In total, 11 studies describing and evaluating interventions to address stigma in the context of infectious disease outbreaks were included in the review.

This review synthesises the current evidence on stigma reduction interventions in the context of infectious disease outbreaks. Despite searching across multiple databases and outbreak-prone diseases, only 11 eligible studies were identified. The scarcity of evaluated interventions in this area is striking given the prominence of stigma in outbreak narratives and guidance. This underscores the need for more systematic attention to how stigma is addressed in preparedness, response, and recovery. While limited, the existing evidence suggests a few promising avenues for stigma mitigation, alongside examples of interventions that had little effect or risked exacerbating stigma.

Among the interventions identified in this review, the strongest evidence of effectiveness was for those embedding anti-stigma messaging alongside health information (17, 18). This aligns with broader literature on infectious disease communication, which emphasises that factual knowledge alone is often insufficient to shift deeply rooted social attitudes and fears (3, 7). In contemporary outbreak settings, where misinformation can spread rapidly through digital and social media channels, there is a critical need for stigma-sensitive messaging delivered by trusted sources (28). However, framing matters: the finding that high-peril messaging may increase stigma illustrates how communication strategies can produce unintended effects when content and tone are not carefully considered (19).

Community involvement and leadership also emerged as an important domain for stigma reduction. Across the qualitative studies, community-led reintegration efforts, educational activities and communication were described as helping to address fear and support acceptance (21–23). These approaches also reflect a broader ethical imperative: outbreak responses should be shaped by, and not only for, affected communities. Such involvement can improve relevance and trust, while reducing the likelihood that response measures unintentionally compound stigma.

All three studies on community involvement included education efforts led by individuals with lived experience. Similarly, the RCT conducted by Valeri et al. (18) featured a video of a person recovered from COVID-19 sharing their experience. In the broader stigma literature, social contact refers to interaction between people with and without a condition and is considered one of the most effective stigma reduction strategies (29–31). The term ‘social contact’ is not commonly used in outbreak stigma reduction contexts, where language associated with infection prevention, such as ‘social distancing’, may complicate interpretation. However, the findings demonstrate how forms of social contact can still be incorporated safely in outbreak contexts, for example through digital platforms or by involving recovered individuals. Such approaches can help foster empathy, challenge stereotypes, and reduce perceived divisions between affected groups and the wider public.

The results also highlight how well-intentioned interventions aimed at reducing stigma may inadvertently exacerbate it. Structural adaptations, such as specially designated services or entrances intended to protect privacy, may reinforce perceptions of “otherness” or ongoing risk and can discourage care-seeking (24). Careful attention to stigma risk in designing and communicating outbreak response and recovery measures is therefore essential. Conceptual frameworks such as the Health Stigma and Discrimination Framework (3) and the hourglass model (9) can support more systematic consideration of how policies, services and communication strategies may influence stigma across the course of an outbreak, and help anticipate and minimise unintended harms.

The review also identified brief psychosocial interventions that yielded rapid reductions in internalised and perceived stigma (25, 26). These findings mirror evidence from the HIV and mental health literature where interventions like peer-led counselling, narrative-based approaches and cognitive reframing have been shown to effectively reduce stigma (32, 33). However, as demonstrated by Techapoonpon et al. (25), the effectiveness of these single-session intervention tends to wane with time when there is no reinforcement or integration into ongoing support. This highlights the need for stigma-reduction interventions designed to achieve durable, long-term impact and for studies to have sufficient follow up to allow for longer-term outcome assessment.

Several features of the available studies limit how confidently their findings can be applied. Quantitative evaluations were generally small, drawn from single contexts, and characterised by short follow-up periods. Outcomes were mostly based on self-completed questionnaires that are vulnerable to social desirability and related response biases. The qualitative studies provided essential insight into context, acceptability and process but did not offer detailed effectiveness data or compare approaches. Taken together, these features mean that the benefits observed in individual studies should be interpreted cautiously.

Heterogeneity in how stigma was defined and measured adds further uncertainty. Several evaluations relied on bespoke measures without psychometric validation or explicit theoretical grounding. This affects confidence in baseline estimates and observed changes. The absence of standardised measures also limits meaningful comparison across studies, restricting the ability to synthesise findings or assess the consistency and magnitude of intervention effects. An earlier review of infectious-disease stigma scales highlighted similar concerns, including lack of robust development processes and missed opportunities to use consistent assessment tools (11). Cross-outbreak instruments, such as the (Re)-emerging And ePidemic Infectious Diseases (RAPID) stigma scales, offer one potential route towards more consistent measurement across diseases and settings, though context-specific piloting remains important (34).

The review has several additional limitations. The included studies were unevenly distributed (six on COVID-19 versus one on mpox), and predominantly from high- and middle-income settings. The paucity of evidence from low-income settings is unlikely to reflect a lack of stigma relevance in these contexts, but rather structural inequities in global research production and evaluation capacity. This restricts the generalisability of our findings to other outbreak disease contexts and to low-resource regions underrepresented in published literature. Finally, most of the included RCTs were assessed to have ‘some concern’ or high risk of bias. This further tempers our confidence in the reported effectiveness of the included interventions.

The weakness of the intervention evidence base is particularly concerning given the pervasiveness of stigma in outbreaks, and the potential for response measures to cause further social division. Building a stronger evidence base will require study designs that can generate insight into both effectiveness outcomes and the processes through which they are achieved. Important next steps include pragmatic trial approaches, such as stepped-wedge cluster RCTs, which can help assess effectiveness under real-world conditions. In addition, qualitative and mixed-methods implementation research is essential not only to document intervention effects, but also to elucidate underlying mechanisms, contextual influences, and the risk of unintended or counterproductive effects, including those arising from well-intentioned outbreak response measures. Until more robust evidence is available, practice may need to be steered by expert consensus guidance, with careful adaptation of evidence from non-outbreak contexts.

Recent guidance illustrates how stigma mitigation can be operationalised in practice despite current evidence gaps. For example, the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) Anti-Stigma Guidelines provide cross-outbreak recommendations for integrating stigma-sensitive approaches into risk communication plans, outbreak preparedness frameworks, and health worker training, including guidance on stigma-sensitive communication, meaningful community engagement, and the design and delivery of respectful outbreak services (35). Such frameworks demonstrate how insights from qualitative and quantitative evidence can be translated into concrete actions across preparedness, response, and recovery phases, rather than implemented as isolated or ad hoc interventions.

The evidence base for stigma-reduction interventions in outbreaks remains limited, offering tentative indications of what may be effective. Nonetheless, several approaches appear promising, including stigma-sensitive risk communication, meaningful community involvement, psychosocial support, and increasing attention to how policies and services may inadvertently reinforce otherness. Strengthening this evidence will require rigorous, contextually-informed evaluation. At the same time, policymakers and outbreak responders can integrate the proposed approaches into preparedness, response, and recovery efforts as practical steps to mitigate stigma, while more robust evidence continues to develop.