1. Mitigating and Measuring Stigma in Health Facilities: The HPP Approach
July 20, 2015
Laura Nyblade, PhD
RTI, International

2. What We Know: Stigma is Universal, prevalent, harmful Actionable
Growing evidence of the effect on key HIV outcomes
Testing (Musheke et al., 2013)
Adherence (Katz et al., 2013)
Linkage entry to care (Govindasamy et al., 2012)
Prevention of mother-to-child transmission (PMTCT) (Turan & Nyblade, 2013)
Actionable
Intervention models and practical tools available for adaptation and scale-up
Measurable
Validated and tested measures
Globally approved indicators
Musheke, M., Ntalasha, H., Gari, S., Mckenzie, O., Bond, V., Martin-Hilber, A., & Merten, S. (2013). A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa. BMC public health, 13(1), 220.
Katz, I. T., Ryu, A. E., Onuegbu, A. G., Psaros, C., Weiser, S. D., Bangsberg, D. R., & Tsai, A. C. (2013). Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. Journal of the International AIDS Society, 16(3Suppl 2).
Govindasamy, D., Ford, N., & Kranzer, K. (2012). Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review. Aids,26(16),
Rangarajan, Suresh, et al. "Risk Factors for Delayed Entrance into Care after Diagnosis among Patients with Late-Stage HIV Disease in Southern Vietnam."PloS one 9.10 (2014): e
Bhowmik, A., et al. "Factors responsible for delayed enrollment for anti-retroviral treatment." Journal of Nepal Health Research Council (2013).
Turan, J. M., & Nyblade, L. (2013). HIV-related stigma as a barrier to achievement of global PMTCT and maternal health goals: a review of the evidence. AIDS and Behavior, 17(7),

3. Growing Recognition in Global Guidance Documents

4. Stigma is a Social Process
That occurs in the context of power
Distinguish and label differences
Associate negative attributes to perceived differences
Separation of “us” from “them”
Status loss and discrimination
(Link & Phelan, 2001)
Discrimination is the end result: Unfair and unjust action toward an individual or group on the basis of:
Real or perceived status or attributes
a medical condition like HIV or AIDS
socioeconomic status
gender
race
sexual orientation or sexuality
(UNAIDS)
Source: Link, Bruce G., and Jo C. Phelan "Conceptualizing Stigma." Annual Review of Sociology:

5. Terminology of stigma Enacted stigma (discrimination)
Anticipated (fear of) stigma
Perceived stigma
Internalized (self) stigma
Secondary (by association) stigma
Compound (layered) stigma
Gender
Poverty/class/race/geography/migrant status
Sexual orientation
Behaviors

6. Stigma-reduction Interventions
Evidence on how to reduce stigma has grown exponentially over the past decade (2003–2013)
From 22 (Brown et al., 2003) to 48 studies (Stangl et al., 2013) included in review articles
Regional breadth of existing stigma-reduction programs has expanded
Stigma-reduction interventions are more likely to use a combination of approaches
Information, skills building, counseling/support, contact, structural and biomedical
8 studies of 48 in Stangle’s review targeted healthcare providers

7. HIV Stigma Measurement
With multiple populations
General population
Revised questions in the latest round of the DHS
People Living with HIV Stigma Index
Health facility
Globally approved indicators
Population
Inclusion in the 2015 WHO Consolidated Strategic Information Guidelines for HIV in the Health Sector
Being considered for inclusion in the PEPFAR SIMS

8. HPP’s Package for Stigma Reduction in Health Facilities
An example of a total facility combination approach

9. Core Components
Assess: Two tools and a user’s guide for implementation
Train: Training menus and material for health workers
Sustain: Facility assessments, action planning, examples for developing codes of conduct and facility policies

10. Assessment Tools
HPP-led consortium of international stakeholders developed, field-tested, and refined a brief measurement tool
Field-tested in six sites
China, Dominica, Egypt, Kenya, Puerto Rico, St. Christopher & Nevis
Two tools
Comprehensive Brief: 21–24 questions
Monitoring Tool: 7 questions
Literature review using PubMed, other databases
Review included published and grey literature, and pre-publication questionnaires
Questions were drawn from ten peer-reviewed articles, three agency reports, and two unpublished questionnaires
Content-development workshop
22 international stigma measurement and programmatic experts participated
Experts reviewed, assessed, and prioritized a comprehensive list of stigma items
Items were selected based on seven criteria
Questionnaire: background section, stigma drivers, enacted stigma, a module on stigma toward pregnant women living with HIV

11. Five Domains of the Comprehensive Tool
Infection control (fear of HIV transmission & avoidance behaviors)
Opinions about PHLIV and KPs (willingness to treat)
Health facility environment (observed and secondary stigma)
Special Module: pregnant women living with HIV
Health facility policies (supplies, training, policies)

12. A Collaborative Implementation and Funding Effort
Overall Coordination
Health Policy Project
USAID; AID-OAA-A (includes PEPFAR)
China
UCLA
NIMH; R01MH S1
Dominica
University of the West Indies
Egypt
U.S. Naval Medical Research Unit
Ford Foundation
Kenya
University of Alabama at Birmingham & KEMRI
Puerto Rico
University of Puerto Rico
NIMH; 1R01MH080694
St. Christopher & Nevis
the 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

13. Training Guide

14. Drawn from a Wide Range of Sources

15. Training Package Based on field application in 9 countries
Can be tailored for different audiences and timeframes
Includes 17 sample workshops and 1 refresher
Sample S&D Training Programs
Half-day workshop for health facility managers
Three-day work shops for medical health workers
Ten-week modular course for medical health workers
Three-hour workshop for doctors on stigma toward key populations
Basic recommendations
Can be tailored for different audiences and timeframe

16. Administrator’s guide
Includes three tools:
Check list for a stigma-free facility environment
Codes of conduct
Action planning guide
Codes of conduct:
Continuous process throughout training or as a separate activity at the end of training
Developed by staff themselves
Negotiated with each other
Commitment to standards of behavior
Posters on facility walls
Reminder to both clients and staff