1. Evidence 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 Countries
July 21st, 2014
Laura Nyblade, Aparna Jain, Manal Benkirane, Li Li, Anna-Leena Lohiniva, Roger McLean, Janet M. Turan, Nelson Varas-Díaz

2. 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 & HPP
Egypt
U.S. Naval Medical Research Unit
Ford Foundation
Kenya
University of Alabama at Birmingham, KEMRI & HPP
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

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)
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.

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
Much of stigma is unintentional, something we do not realize we are doing.

5. Data, 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.

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)
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

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)
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.

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

11. Stigmatizing avoidance behavior variables
Avoid physical contact
☐ Yes ☐ No ☐ Not applicable
Wear gloves during all aspects of the patient’s care (history-taking, physical examination, etc.)
Wear double gloves
Use any special measures with patients living with HIV that you do not use with other patients

12. Worry 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

13. Multivariate logistic regression: Health facility environment on worry
Predictor
Model 1 (n=814)1
OR (CI)
Support on none or one item
1.00
Support on two items
0. 73 (0.43, 1.25)
Support on all items
0.53 (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 < 0.05
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
Model 1 (n=659) 1
Predictor
OR (CI)
Not worried
1.00
Worried
1.88 (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 < 0.001
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

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
This 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---

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