1. Laura Nyblade, PhD. HP+/RTI International
Reducing Health Worker Stigma and Discrimination Is Critical to Reaching Targets and Is Possible: Evaluation Results of a Whole-Facility Approach in Ghana
Laura Nyblade, PhD. HP+/RTI International

2. Acknowledgements Coauthors: Supported by:
Nii Akwei Addo, Educational Assessment Resource Center
Kyeremeh Atuahene, Ghana AIDS Commission
Emma Gyamera, Educational Assessment Resource Center
Christin Stewart, RTI International
Suzie Jacinthe, U.S. Agency for International Development
Emmanuel Esandoh, U.S. Agency for International Development
Nabil Alsoufi, U.S. Agency for International Development
Richard Vormawor, Educational Assessment Resource Center
John Kraemer, Georgetown University
Supported by:
USAID and PEPFAR
Global Fund

3. The Total Health Facility Approach to S&D Reduction: Three Phases
Jan 2017 – Aug 2018
Sept 2017 – March 2018
March 2018 – Sept 2018
Assessment (Baseline)
Intervention
Evaluation (Endline)
Quantitative surveys:
Health facility staff of all levels
Clients living with HIV
20 facilities in 5 regions: Ashanti, Brong Ahafo, Eastern, Greater Accra, & Western
Based on findings from Phase 1
Designed in partnership with intervention facilities (5 total, 1 per region)
Participatory skills building plus other activities
Quantitative surveys:
Health facility staff Clients living with HIV
10 facilities in five regions
5 intervention and 5 comparison facilities
Dissemination at facilities

4. Evaluation Methods
Ten district-level health facilities in five highest HIV prevalence regions; five intervention, five comparison
Baseline (N=1,149)
Endline (N=1,149)
Pre-Post intervention comparison through baseline- endline surveys with health facility staff of all levels (clinical and non-clinical)
Estimated before-after trends and difference-in- differences
Ashanti, Brong Ahafo, Eastern, Greater Accra, & Western

5. Summary and example of Results

6. Summary of Results
Statistically significant before-after improvements in most outcome domains in the intervention facilities
Significant difference-in-differences reductions between intervention and comparison facilities
Intervention facility staff report significantly greater improved behavior of staff towards clients relative to comparison sites, compared to previous year
Staff: intervention facilities were 21.5% (p=0.019) more likely to report that behavior toward patients was much better at follow-up than staff at the comparison facilities
Clients from intervention facilities were 28% more likely to report that behavior toward patients was much better at follow-up than staff at the comparison facilities

7. Fear of Transmission and Stigmatizing Avoidance Behaviors
Pre-Post change in intervention facilities:
Worry about HIV transmission declined by 26.9% (p=0.000),
Stigmatizing avoidance behaviors declined by 23.7%; (p=0.000)
Difference-in-differences: Greater decline in intervention over comparison facilities:
Unnecessary fear: 23.9% (p<0.001)
Stigmatizing avoidance behaviors: 15.7% (p=0.011)
“I am free! As a model of hope (PLHIV attached to facilities) I was called to come to the ward to care for  (wash, change the patient bed, clothes etc) in-patients with HIV who didn’t have family around. They would call me at all hours of night or day to come and take care of “your people”. Now, the staff take care of the patients themselves. I am now free!!
Mr. Theophilus Agbogyalo – Model of Hope, Agomanya Hospital

8. Understanding and interactions with key populations improved
Preference not to treat men who have sex with men
Pre-Post change in intervention facility: 15% decline (P=0.000)
Difference-in-differences: 14.2% (p=0.001) greater reduction in intervention over comparison facilities
“Since the training we have seen an increase in MSM living with HIV coming for services. We think this is mostly due to the change in our staff and how they interact with key populations. We also see MSM coming freely for their medicines during regular facility hours. Before they preferred coming after hours, to avoid being seen by staff.”
Mr. Kofi Atakorah-Yeboah Jnr, Champion Team Member, Bekwai Hospital

9. Key Elements of the Total Health Facility Approach
Utilizes data to catalyze action, tailor approach & evaluate progress
Strengthens capacity for facility-owned and driven stigma-reduction for a sustainable response
Early and continued engagement of facility management
Trainers: both facility staff and clients
Champion teams that design and implement activities
Uses participatory approaches to learning and behavior change
Creates new opportunities for contact outside the provider-client relationship
Recognizes that all staff at a facility have a role to play to reduce stigma

10. Action to reduce facility stigma is possible!
Global measurement and intervention tools are easily adaptable across diverse contexts