Presentation on theme: "Evidence from Six Countries"— Presentation transcript:
1Evidence from Six Countries Creating Stigma-Free Health Facilities: Lack of HIV Care Policies, Protocols, Materials Exacerbate Health Worker Fear of HIV Transmission and Stigmatizing Avoidance Behaviors:Evidence from Six CountriesJuly 21st, 2014Laura Nyblade, Aparna Jain, Manal Benkirane, Li Li, Anna-Leena Lohiniva, Roger McLean, Janet M. Turan, Nelson Varas-Díaz
2Collaborative implementation and funding effort Overall CoordinationHealth Policy ProjectUSAID; AID-OAA-A (includes PEPFAR)ChinaUCLANIMH; R01MH S1DominicaUniversity of the West Indies & HPPEgyptU.S. Naval Medical Research UnitFord FoundationKenyaUniversity of Alabama at Birmingham, KEMRI & HPPPuerto RicoUniversity of Puerto RicoNIMH; 1R01MH080694St. Christopher & Nevisthe paper presents the results of a 2.5 year collaborative/collective effort that wouldn’t have been possible without a truly joint effort of many people, institutions, funders etc etc.—and flash it up
3Why Stigma & Health Systems? Stigma is directly related to three of the WHO health system building blocksService delivery: quality; demand for care; access; uptake and retention; equityHealth workforce: norms; standards; retentionLeadership and governance: policies; procedures; oversight and regulationHealth system factors can cause stigmaPerceived lack of confidentiality and poor attitude of health personnel was a barrier to HIV testing (Musheke et al, 2013)Health system factors can moderate stigma & its negative influence on key health outcomesCompassionate providers, supportive clinical environment for patients, clinical programs designed to address care for the entire family mitigated the effect of stigma on ART adherence (Katz et al., 2013)For example, key elements of the service delivery building block that are affected by or affect stigma include: quality, demand for care; access; uptake and retention; equity while Leadership and governance: especially at the facility level is key to creating an environment—through policies, procedures, supplies-that support staff to provide stigma-free services.
4Stigma within health facilities Forms of stigmaAvoidance behaviors (e.g. double gloves, selective use of gloves)Enacted stigma (denial of services, lower quality of care, breaches of confidentiality, verbal abuse & gossip)Secondary stigma experienced by health facility staffKey drivers of stigma within facilitiesLack of awareness of what stigma is and what it doesAttitudesWorry about HIV transmissionHealth facility environmentMuch of stigma is unintentional, something we do not realize we are doing.
5Data, Key Questions & Methods The data I will present here focus on just one small aspect of stigma and health systems, in particular health systems and one of the key drivers of stigma in health facilities---worry about HIV transmission on the job.
6BackgroundHPP-led consortium of international stakeholders developed, field-tested, and refined a brief measurement toolField-tested in six sitesChina, Dominica, Egypt, Kenya, Puerto Rico, St. Christopher & NevisSelf and interviewer administeredRange of facilities, varied by siteBoth clinical and non-clinical staffN ranged from 300–350 per siteTotal sample size: 1,893 (72% female)Literature review using PubMed, other databasesReview included published and grey literature, and pre-publication questionnairesQuestions were drawn from ten peer-reviewed articles, three agency reports, and two unpublished questionnairesContent-development workshop22 international stigma measurement and programmatic experts participatedExperts reviewed, assessed, and prioritized a comprehensive list of stigma itemsItems were selected based on seven criteriaQuestionnaire: background section, stigma drivers, enacted stigma, a module on stigma toward pregnant women living with HIV
7Key questionsQ.1: What is the relationship between facility environment and worry about HIV infection on the jobDependent variable: Worry about acquiring HIV in job functionsPredictor: Health facility environmentQ.2: What is the relationship between worry about HIV infection on the job and self-reporting stigmatizing avoidance behaviorsDependent variable: Stigmatizing avoidance behaviorsPredictor: Worry about acquiring HIV in job functionsMultivariate logistic regressions adjusted for background characteristicsModels adjusted for staff type, age, education, sex and country
9Health facility environment variables (n=1,800) Do you have access to post-exposure, prophylactic medications in your health facility?Do you strongly agree, agree, disagree, or strongly disagree with the following statements?There are adequate supplies (e.g., gloves) in my health facility that reduce my risk of becoming infected with HIV.There are standardized procedures/protocols in my health facility that reduce my risk of becoming infected with HIV.
10Composite indicator of health facility environment items (n=1,800)
11Stigmatizing avoidance behavior variables Avoid physical contact☐ Yes ☐ No ☐ Not applicableWear gloves during all aspects of the patient’s care (history-taking, physical examination, etc.)Wear double glovesUse any special measures with patients living with HIV that you do not use with other patients
12Worry about acquiring HIV in job functions: Items with potential risk of HIV transmission How worried would you be of getting HIV if you did the following?If any of the following is not one of your job responsibilities, please select “Not applicable.”Took the temperature of a patient living with HIV☐ Not worried ☐ A little worried ☐ Worried ☐ Very worried ☐ Not applicable
13Multivariate logistic regression: Health facility environment on worry PredictorModel 1 (n=814)1OR (CI)Support on none or one item1.00Support on two items0. 73 (0.43, 1.25)Support on all items0.53 (0.31,0.90)*In this analysis we explore the relationship between the health facility environment and fear, as measured by the composite variables we just looked at. Model 1 looks at the relationship between health facility environment and worry about transmission in job functions that have potential risk, while model 2 looks at the relationship between health facility environment and worry about transmission in actions that carry no risk. Focusing on the bolded numbers in the bottom row, we see that respondents who report support on all items report have a roughly 50% lower odds of worry on either variable compared to those who report support on none or one item, significant at a p-value of less than .05.*p-value < 0.051 Worry items with potential risk of HIV transmission2 Worry items with no risk of HIV transmissionModels adjusted for staff type, age, education , sex and country
14Multivariate logistic regression: Worry on avoidance behaviors Model 1 (n=659) 1PredictorOR (CI)Not worried1.00Worried1.88 (1.30, 2.73)**Now turning to our second analysis---we examine the relationship between worry and stigmatizing avoidance behaviors In model 1, respondents who report worry about transmission in actions that carry potential risk have odds of reporting avoidance behaviors that are 1.88 times higher than those who report no fear. While respondents who report worry in actions that carry no risk of HIV transmission have odds of reporting stigmatizing avoidance behaviors that are 3.18 times higher than respondents who report no worry.*p-value < 0.05** p-value < 0.0011 Worry items with potential risk of HIV transmission2 Worry items with no risk of HIV transmissionModels adjusted for staff type, age, education, sex and country
16Stigma matters to health systems Health system factors can drive or moderate stigmaHealth facility environment can influence staff worry about HIV transmissionWorry in turn is related to stigmatizing avoidance behaviors that can lead to HIV status disclosureStigma can undermine health systems & health outcomesQuality of care, access, equityUptake of HIV testing, linkage to ART care, adherenceThis study has examined just one small corner of the issue of stigma and health systems—demonstrating that there is a relationship between health facility environment (in terms of staff perceptions of their safety/ability to protect themselves from HIV at work) and worry about HIV transmission—which is a demonstrated driver of stigmatizing behavior in (and outside) health facilities—as illustrated by this data --where worry is related to self-reporting use of stigmatizing avoidance behaviors that risk visibly marking a patient living with HIV, thereby disclosing their status to all around them.The experience, or fear of experiencing, stigma in health facilities (including fear of disclosure of status) undermines health systems by lowering quality of care, which in turn limits access and reduces demand for services, undermines equity, particularly for groups who experience multiple stigmas, for example stigma towards key populations, which is often layered on top of HIV stigma—and ultimately undermines health.On the other hand, health systems can be a positive force in moderating or combating stigma that clients fear or are experiencing outside the health system. For example, as Katz and Musheke—referenced earlier show—by the way in which services are organized (to minimize risk of disclosure), or by providing quality services, in particular a welcoming & supportive environment---
17Action is possible Make stigma an explicit component of quality by: Including stigma indicators in quality assessmentsIntegrating stigma-reduction into quality-improvement processesIncorporate stigma-reduction into:Training—pre and in-service (for all staff)Licensing and accreditation for individuals & facilitiesPerformance assessment & supervisionEnsure guidelines, standards, policies support provision of stigma-free services & non-discriminatory careStigma-reduction tools and measures for health facilities existParticipatory stigma-reduction training materialsAdministrators guideStandardized measures & approved indicators