1. NIMH Satellite on Stigma Reduction Washington, DC July 22, 2012 James Blanchard, MD, MPH, PhD Centre for Global Public Health University of Manitoba

2. Research and Programs – the “Perspective Gap” Research paradigm –Relies heavily on theory to build knowledge and develop interventions –Focuses on internal validity for building knowledge and testing interventions –Prioritizes “getting research into practice” Program paradigm –Relies on experience and community perspectives to develop interventions –Focuses on local context and community responses to assess interventions –Emphasizes “getting research out of practice”

3. Research and Programs – the “Implementation Gap” Research paradigm –Emphasizes adherence and fidelity to “proven” interventions. –Requires clear, measurable indicators to assess progress and effectiveness. –Is often constrained by lack of robust program contexts within which to conduct research. Program paradigm –Emphasizes adaptation to local situations and flexibility in design. –Often gives priority to experiential evidence and key informant feedback to measure success. –Often is constrained by resources and expertise to engage in research

4. “…the systematic application of theoretical and empirical scientific knowledge to improve the design, implementation and evaluation of public health programmes.”

5. An example – Addressing stigma and discrimination in female sex work in India

6. Stigma and Discrimination – Issues for FSWs in India Poverty and low social standing: –Economic dependency and lack of power over resources –Lack of access to health services and other social entitlements –Lack of education and skills to negotiate with government and other power structures Moral and legal aspects: –Promotes / sanctions harassment, exploitation and violence by police, power brokers and members of their own families and communities –Internalization of stigma resulting in feelings of unworthiness and lack of entitlement to human rights HIV: –Seen as a threat to the community, accentuating social exclusion and stigma and discrimination

7. Program Response – Structural Interventions Structural Interventions Public attitudes and stigma Media advocacy Support local organizations Social and economic issues Promote access to social entitlements Strengthen CBOs Violence and exploitation Police sensitization Crisis response system Legal empowerment

8. Police Officers Trained in Each District (as of October 2008) DistrictsTotal No. of Police Officers to be trained Total No. of Police officers trained % of coverage Bangalore (R )1929 20611% Bangalore (U)3338122637% Bellary1630 141287% Chitradurga1333118488% Davangere728880121% Gadag52142882% Gulbarga13111461111% Haveri57731554% Kolar15661626104% Shimoga118922219% Uttar Kannada165822113% Belgaum99580280% Bijapur149137820% Bagalkot79524631% Raichur140952737% Dharwad165234020% Total22,12210,97952.8%

9. Knowledge and Attitudes of Police Officers Before and After Training

10. FSWs Reporting Being Beaten or Raped in Past Year: Polling Booth Surveys (13 Districts) and IBBA (5 Districts)

11. Program Response – Community Mobilization Enhance the dignity and self-esteem of FSWs Support FSWs to develop a strong “shared voice” Build the capacity of collective organizations to effectively advocate for their rights and address stigma and discriminition

12. Progress in the Development of FSW Collectives Indicators March 2007March 2008Jan 2009 Amount Deposited in SHGs (INR) -5,102,50015,419,203 # of collectives registered 91920 Total membership in the collectives 12,11829,28935,983 Total annual budget of the collectives 5,210,00024,385,11528,565,456 Total corpus fund (cumulative) 1,051,0002,143,2862,563,209 Number of CBOs with FCRA numbers 002 Number of peers promoted to higher role -158203

13. Constraints with Program Performance Measurement Lack of theoretical of conceptual framework: –Difficult to translate across contexts Lack of explicit empowerment objectives at the individual level: –Difficult to measure diverse community needs and empowerment progress

14. Power Within Power with Others Power over Resources Socio- demographic characteristics Community Mobilization Program and structural interventions Empowerment Dimensions Power imbalances Social exclusion Vulnerability Disempowering social context Power to Address “Program Science” Framework

15. FSW Empowerment Domains –“Power within” – self-esteem, and confidence to participate in meetings with other sex workers or health/social workers. –“Power with” – confidence in the ability to work together and support each other, and the benefits of collectivization. –“Power over resources” – represented by the possession of social entitlements, including a bank account, voter ID and ration cards.

16. Levels of Empowerment, By District

17. Key Findings Younger women scored lower in all empowerment domains. There was considerable variation between districts in power domains, but generally, in districts with weaker CBO programs, scores were lower. Duration of time exposed to the program and number of program contacts was positively associated with “power within” and “power with” in most districts.

18. Key Findings (2) “Power within” was associated with greater self-efficacy for condom use with regular partners, and with higher service utilization, in all districts. “Power with” was associated with greater autonomy, reduced reported violence, and increased self-efficacy for service utilization in three districts, and with self-efficacy for condom use in all districts.

19. Scaling up Strategies to reduce Stigma – Program Science approaches Develop “program-science” platforms through innovative funding models: –Diverse program contexts –“Embedded” research and researchers –Coordinated funding models – programs and research funding Further develop practical conceptual frameworks for research and program development: –Address the complexity of relationships and pathways. –Develop analytic approaches and measurement tools

20. Final thoughts Put the community at the centre of “program science” platforms: –Systematically engaged to define the issues and research questions –Participating in all aspects of research design and conduct

21. Acknowledgements Karnataka FSW community and CBOs Karnataka Health Promotion Trust –HL Mohan, V Gurnani, P Bhattacharjee, S Isac, R Prakash University of Manitoba –S Moses, BM Ramesh, A Blanchard –M Shahmanesh (Univ. College London)