1. Stigma Reduction From Theory to Interventions Arjan E.R. Bos & Sarah E. Stutterheim

2. A definition of stigma An attribute that results in widespread social disapproval A discrediting social difference that yields a “spoiled social identity” Two fundamental components: -recognition of difference -devaluation

3. Four different types of stigma

4. Public stigma People’s social and psychological reactions to someone they perceive to have a stigmatized condition. Public stigma comprises cognitive, affective, and behavioral reactions of those who stigmatize.

5. Self-stigma Social and psychological impact of possessing a stigma. It includes both the apprehension of being exposed to stigmatization and the potential internalization of the negative beliefs and feelings associated with the stigmatized condition.

6. Stigma-by-association Social and psychological reactions to people who are somehow associated with a stigmatized person or how people react to being associated with a stigmatized person

7. Structural stigma Legitimatization and perpetuation of a stigmatized status by society’s institutions and ideological systems

8. Designing theory and evidence-based stigma interventions

9. Intervention Mapping

10. Step 1: Needs assessment Experiences with hiv-related stigma in the health care sector (N = 667): Dentist 28.8% Hospital 26.2% General practitioner 19.2%

11. Step 1: Needs assessment Manifestations of hiv-related stigma in the health care sector (N = 262): Advice to conceal 25.2% Physical distance 20.6% Excessive protective measures20.6% Differential protective measures16.8% Àdvice to disclose14.9% Breached confidentiality13.7% Awkward social interaction12.6% Care avoidance11.8% Rude and unkind behavior10.7% Blame10.3% Sympathy and support76.3%

12. Step 1: Needs assessment Interviews with Health professionals (N = 14) Little experience with PLWH and only basic knowledge of HIV. They contended that PLWH are treated equally and that HIV is no longer stigmatized. However, they also reported fear of occupational infection, resulting in differential precautions. Additionally, they conveyed labeling PLWH’s files to warn others, and curiosity regarding how patients acquired HIV.

13. Step 1: Needs assessment Interviews with persons living with hiv (N = 22) Negative experiences with health professionals: Awkward interactions, irrelevant questions, rude treatment, blame, pity, excessive or differential precautions, care refusal, unnecessary referrals, delayed treatment, poor support, and confidentiality breaches. Positive experiences with health professionals: Equal treatment, being valued as a partner in one’s health, social support provision, and confidentiality assurances.

14. Step 2: Define suitable programme objectives Health professionals will interact with all HIV positive patients in a nonstigmatizing fashion Health professionals will interact with all HIV positive colleagues in a nonstigmatizing fashion

15. Step 2: Define suitable programme objectives Persons living with hiv will be empowered in their interactions with health professionals Persons living with hiv will be resilient against the negative effects of perceived HIV-related stigma from health professionals

16. Step 3: Select theory-based intervention methods and practical strategies Intervention methods are general techniques or processes that can generate change in behaviors or environments (e.g., modeling, interpersonal contact, persuasive communication, consciousness raising Practical strategies are specific techniques used to apply the theoretical methods (e.g. testimonials, written information).

17. Step 3: Select theory-based intervention methods and practical strategies Changing public stigma: -Education -Contact Integration of education and contact approaches may be most effective for stigma change (Corrigan & Fong, 2014; Brown et al., 2003)

18. Step 3: Select theory-based intervention methods and practical strategies Changing self-stigma: -Challenge stigmatizing self- statements (psycho-educational strategies, CBT, ACT) -Interventions that enhance skills for coping with self-stigma through improvements in self-esteem, empowerment, and help-seeking behavior. (Corrigan & Fong, 2014; Mittal, Sullivan, Chekuri, Allee & Corrigan, 2012)

19. Step 3: Select theory-based intervention methods and practical strategies

21. Step 4: Produce programme components and materials

23. Step 5: Design an implementation plan Potential adopters and implementers present in the work group (at the start of the project). We tied into existing networks that could easily promote the website. Presented the website at the National HIV Conference and at the Nursing Experience conference, and sent out a press release prior to launching the site. We ensured that the website would remain online after the project’s funding ended by transferring ownership of the site to the Dutch HIV Association

24. Step 6: Design an evaluation plan Process evaluation -Reach and exposure (google analytics and vimeo statistics) -Interviews with health professionals and persons living with hiv (think-aloud approach while navigating the website) Results process evaluation provide relevant entry points for improving positiefzorgt.nl

25. Future directions

26. www.positiefzorgt.nl E-mail: Arjan.Bos@ou.nl Twitter: @arjanbos Web: https://sites.google.com/site/arjanerbos Questions?