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July 21 st , 2014

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 Countries.

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July 21 st , 2014

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  1. 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 Countries Laura Nyblade, Aparna Jain, ManalBenkirane, Li Li, Anna-LeenaLohiniva, Roger McLean, Janet M. Turan, Nelson Varas-Díaz July 21st, 2014

  2. Collaborative implementation and funding effort

  3. Why Stigma & Health Systems? • Stigma is directly related to three of the WHO health system building blocks • Service delivery:quality; demand for care;access; uptake and retention; equity • Health workforce:norms; standards; retention • Leadership and governance: policies; procedures; oversight and regulation • Health system factors can cause stigma • Perceived 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 outcomes • Compassionate 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)

  4. Stigma within health facilities • Forms of stigma • Avoidance 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 staff • Key drivers of stigma within facilities • Lack of awareness of what stigma is and what it does • Attitudes • Worry about HIV transmission • Health facility environment

  5. Data, Key Questions & Methods

  6. Background • 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 • Self and interviewer administered • Range of facilities, varied by site • Both clinical and non-clinical staff • N ranged from 300–350 per site • Total sample size: 1,893 (72% female)

  7. Key questions • Q.1: What is the relationship between facility environment and worry about HIV infection on the job • Dependent variable: Worry about acquiring HIV in job functions • Predictor: Health facility environment • Q.2: What is the relationship between worry about HIV infection on the job and self-reporting stigmatizing avoidance behaviors • Dependent variable: Stigmatizing avoidance behaviors • Predictor: Worry about acquiring HIV in job functions • Multivariate logistic regressions adjusted for background characteristics • Models adjusted for staff type, age, education, sex and country

  8. Results

  9. Health facility environment variables (n=1,800)

  10. Composite indicator of health facility environment items (n=1,800)

  11. Stigmatizing avoidance behavior variables

  12. Worry about acquiring HIV in job functions: Items with potential risk of HIV transmission

  13. Multivariate logistic regression: Health facility environment on worry *p-value < 0.05 1 Worry items with potential risk of HIV transmission 2 Worry items with no risk of HIV transmission Models adjusted for staff type, age, education , sex and country

  14. Multivariate logistic regression: Worry on avoidance behaviors *p-value < 0.05 ** p-value < 0.001 1Worry items with potential risk of HIV transmission 2 Worry items with no risk of HIV transmission Models adjusted for staff type, age, education, sex and country

  15. Conclusions

  16. Stigma matters to health systems • Health system factors can drive or moderate stigma • Health facility environment can influence staff worry about HIV transmission • Worry in turn is related to stigmatizing avoidance behaviors that can lead to HIV status disclosure • Stigma can undermine health systems & health outcomes • Quality of care, access, equity • Uptake of HIV testing, linkage to ART care, adherence

  17. Action is possible • Make stigma an explicit component of quality by: • Including stigma indicators in quality assessments • Integrating stigma-reduction into quality-improvement processes • Incorporate stigma-reduction into: • Training—pre and in-service (for all staff) • Licensing and accreditation for individuals & facilities • Performance assessment & supervision • Ensure guidelines, standards, policies support provision of stigma-free services & non-discriminatory care • Stigma-reduction tools and measures for health facilities exist • Participatory stigma-reduction training materials • Administrators guide • Standardized measures & approved indicators

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