Sri Lankan Experience HIV Stigma Reduction Interventions for

Healthcare Workers

Introduction

• Stigma has often been associated with disfiguring or incurable diseases, in particular diseases that society perceives to be caused by the violation of social norms, including those that sanction sexual behaviour.

• HIV/AIDS is a good example of this type of disease (Crandall and Moriarty 1995)

Introduction to stigma

• Societal labeling of and individual or group as different or deviant because of a “discrediting attribute” (Goffman 1963)

• HIV/AIDS is a good example of this type of disease (Crandall and Moriarty 1995)

More Recently;

• Stigma has been defined as a dynamic process that is linked to competition for power and tied into existing social mechanism of exclusion and dominance (Link and Phelan 2001)

• Social process that involves identifying and using “differences” between groups of people to create and legitimize social hierarchies and inequalities (Parker and Aggleton 2002)

UNAIDS defines HIV-related stigma and discrimination as:

• A ‘process of devaluation’ of people either living with or associated with HIV and AIDS

• Discrimination follows stigma and is the unfair and unjust treatment of an individual based on his or her real or perceived HIV status.

stigma and discrimination are major “road blocks” to universal access to HIV prevention, treatment, care and support

Reduce an individual’s willingness to• Practice prevention• Seek HIV testing• Disclose his or her HIV

status to others• Ask for (or give) care and

support• Begin and adhere to

treatment

Range of stigma and discrimination

Enacted Stigma (stigma in action)

Discrimination

Unlawful acts such asDismissal from employment;Refusal from healthcareChasing from home/village

Gossip, IsolationRejectionBlamingInsultIgnoreNot talkingNot listening

stigma

How to measure stigma

Recommended Indicators and Questions are Segmented into Three Populations

1. Community (different tools)2. Health care workers (20-item stigma index used

in Sri Lanka)3. People living with HIV/AIDS (PLHIV Stigma Index

collaborative effort of GNP+, ICW, IPPF, and UNAIDS)

Baseline assessment of stigma among HCWs against PLHIV

in Sri Lanka

20-item Stigma IndexTest-20 stigma index (T20 stigma index)

National Hospital of Sri Lanka De Soysa Maternity Hospital Lady Ridgeway Hospital for Children

Castle Street Hospital for Women

Study Setting

National STD/AIDS Control Programme

Base Hospital, Angoda

20-item Stigma Index among HCWs

• Design – Cross sectional descriptive study

• Population – Healthcare workers in six major tertiary care institutions in Colombo.

• Sample - A convenience sample of 832 healthcare workers. – 130 physicians– 205 nurses– 92 medical laboratory

technicians– 154 attendants and – 251 labourers.

• Data collection tools - A stigma index was developed aimed at quantifying levels of stigma among health workers against PLHIV.

• The internal consistency of the scale was 0.711 (Cronbach’s alpha).

• Responses to the stigma index were scaled using the Likert scale: [Agree (1), Can’t say (2), Disagree (3)].

• The Index scores ranged from 20 to 60.

• Higher scores indicated higher levels of stigma. The data was analysed using SPSS v16.

20-item stigma index

• The median age of the sample was 41 years (SD, 10.6 years).

• The healthcare workers surveyed had an average of 15 years of work experience in their respective jobs.

• Over 60% had provided care to an HIV-positive patient.

• The median score for the stigma index was 38.3 (46% in percentage scale) and ranged from 36 to 40 (40%-50% as a percentage).

Poster presentationPoster was presented at the 11th ICAAP in 2013 from 18-22 November 2013 at Queen Sirikith Convention Centre, Bangkok, Thailand

Stigma Reduction InterventionTwo-day, activity based workshop

Main components of the intervention were

1. Welcome and pre-test2. Introduction to the workshop

3. Expectations activity (Group work and presentation)4. Character Card activity (Res and roles of characters in a household)5. Understanding the HIV situation (Lecture discussion)6. Natural History of HIV infection (Lecture discussion)7. Introduction to HIV stigma and discrimination (Lecture discussion)8. Problem tree activity (cause and effect)9. Agree, Disagree activity (exploring thoughts)10. Recognizing our own communication (Stigmatizing or non-stigmatizing) 11. PLHIV testimonials and group discussions12. Risk card activity (understanding the personal and professional risk)13. Standard precautions (Lecture discussion)14. HIV testing models (Lecture discussion)15. Post-test and closing

Effectiveness of the intervention in Reducing the Stigma and Discrimination

• The Welcome2care (W2C) tool showed significant improvements in stigma reduction among the nurses from initial 76% to post-training result of 89% using Wilcoxon Signed rank Test (p=0.001)

• This finding was consistent in other workshops carried out.

• This shows the effectiveness of peer pressure on changing the attitudes.

Poster presentationPoster was presented at the 11th ICAAP in 2013 from 18-22 November 2013 at Queen Sirikith Convention Centre, Bangkok, Thailand

Thank you

ස්තුතියි