Principals, Approaches
and Tools for
Stigma-Reduction in
Health Facilities
Laura Nyblade, PhD
Senior Technical Advis or , Stigma & Discrimination
Health Policy Project and RTI
Presentation “Guide”
Background
Why
Definitions & Conceptualization
Forms & consequences
Overview of general stigma-reduction
program strategies
Examples of how they have been
applied in health care settings
Tools & Resources
“…. If we do not appreciate
the nature
and impact of stigma, none
of our interventions can
begin to be successful.”
– Edward Cameron, Constitutional
Court Justice in South Africa
Why?
Powerful social process that:
Turns “difference” into inequity &
disadvantage
Maintains/upholds inequitable structures
Leads to social & economic exclusion
Fuels and can be used to justify violations of
human rights, discriminatory policies & laws
Intensifies & sustains vulnerability
Impedes access to health & other services
Stigma impedes programmatic efforts
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Prevention
Testing
Disclosure
Risk Recognition
Treatment
Treatment
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Access
Timely uptake
Adherence
Delivery/Quality of Care
Human Capital
Health care providers
receiving care
Secondary S&D
Forms-Impact on People’s Lives
Physical and social isolation
Loss of relationships
Gossip & Verbal Abuse
Loss of livelihood
Loss of housing
Rejection by peers
Loss of reputation
Violence
Denial or sub-standard health care
Internalized stigma
Forms-Health Providers
Stigma Indicators Working Group, Tanzania, 2005
Neglect
 Had to wait longer
 Not having bed pans
changed
 Receiving less
care/attention
Differential treatment
 HIV test required before
care was given
 HIV test required before
scheduling surgery
 Using gloves for non invasive exams
 Extra precautions in
sterilizing instruments
Denied care
 Denied treatment
 Referral to another
provider/facility
 Senior provider pushed client to
a junior provider
 Junior provider pushed client to a
senior provider
Lack of consent
 HIV testing without consent
 Disclosing HIV status to
family without client’s
consent
Verbal stigma
•
Gossip about a client’s HIV
status
•
Scolding or blaming a client
“… I overheard two nurses talking about
me…. that I am HIV positive. After having
the baby, they put me in a separate room, no
one came to look after me.
…When I went home, family members
refused to let me stay there. I had to rent
my own room and stay alone with my baby
and no one from the family came to see me.
….As soon as our customers learned that we
are HIV positive, they stopped coming and
our business collapsed.”
Shared in an ISDS/ICRW stigma -reduction workshop,
2002
Definitions and
Conceptualization
Stigma-Goffman, 1963
“An attribute that is deeply discrediting [and that
reduces the bearer] …from a whole and usual
person to a tainted, discounted one.”
By regarding “others” negatively, an individual
or group confirms their own “normalcy” and
legitimizes their devaluation of the “other.”
“Disqualification from full social acceptance”
Social Process (Link & Phelan, 2001)
Distinguish & label
differences
Associate negative attributes
to perceived differences
Separation of ‘us’ from ‘them’
Status loss & discrimination
Discrimination
Unfair and unjust treatment of an
individual based on the basis of
the:
real or perceived status or attribute
(e.g. medical condition)
belonging, or being perceived to
belong, to a particular group (UNAIDS)
Cycle of Stigmatization
Marker
Greater susceptibility and
vulnerability to HIV & AIDS
Discrimination
Adapted from Sartorius, N., 2006.
Loading
Stigma
What works to reduce
HIV Stigma and
Discrimination
Successful programs
Put stigmatized groups at the core
Target a range of groups; Create alliances &
form new partnerships for influence and
expanded reach
 Foster interaction between groups experiencing stigma
& those perpetrating it. “Contact strategies”
 Model desirable behavior, hold up & reward role
models
Employ a combination of approaches, while
targeting a range of groups
Address immediately actionable drivers
Create Understanding:
Close the Intention-Action Gap
Foster understanding and
motivation for stigma
reduction by creating:
–Recognition of stigma
–The benefits of reducing it
–Safe space to reflect and
gain skills for change
Address HIV Transmission
Fears & Misconceptions
How it is and is not transmitted
In-depth information
Interactively: Allow for
• “Yes I know that, but why…?”
Listen, learn & respond to specific
fears related to daily living & work
context
Discuss and Challenge the
‘Taboo’
 Provide safe spaces to discuss,
reflect, understand and question:
– The values and beliefs that underlie
stigma and discrimination
 Where they come from
 What they do
– Address the multiple intersecting &
associated stigmas of HIV
– Sex workers, men who have sex with
men, drug users
Immediately Actionable Causes
• Lack
of awareness
• Fear of casual contact
• Linking HIV with socially “improper” behavior
Individual
Environmental
Structural
• Address attitudes
and behaviors
• Meet needs for information,
training, and supplies
• Policies, laws, and
institutions
Stigma &
DiscriminationReduction program in
Health Services
Some examples
Building institutional Support for
change in Vietnam (Horizons/ISDS/ICRW)
Relationship building with hospital authorities
Conducted & shared Baseline Research Results
Trained all cadres on:
Fear Driven Stigma: HIV transmission and
universal precautions
Socially Driven Stigma (“blame & “shame”)
Tools Development: Checklist, toolkit
Participatory development of hospital policies
Improvements in structural environment
 E.g. hand-washing facilities, sharps containers
Training
4 half-days
½ day basic HIV knowledge
1 day on Universal Precautions
½ day on social stigma co-facilitated by
PLHIV
 Naming stigma through pictures
 What is the meaning of stigma
 Naming stigma in hospitals
 Forms, Causes, Consequences
 How it feels to be stigmatized
Joint development of “Safe
and Friendly” hospital policies
Each trained group developed their own
policy & presented it in plenary to hospital
Steering committee took all comments &
combined for final hospital policy
 Access to services by PLHIV
 HIV counseling and testing
 Confidentiality
 Universal Precautions
 Training on HIV and AIDS
 Dissemination of policy
Posters of policy posted throughout hospitals
Hospitals showed improvements
 Significant declines in the
labeling of patients’ files
and beds with their HIV
status.
 Better hospital-wide
implementation of
universal precautions.
 Significantly improved mean scores on
fear-based and value-based stigma
indices among HWs .
Building institutional Support
for change
Partnering with hospitals as partners
not critics
Participatory approaches; evidence
of need/problem
Involving all categories of hospital
staff
Inclusion of people living with HIV as
co-facilitators
Development of practical tools
Creating partnerships &
reducing distance
between health care
providers and
stigmatized clients
Reducing Stigma & Discrimination
Towards Sex Workers
Ashodaya-Samithi, Mysore,
India
• Trained Peer Patient
advocates placed in
Public Hospitals
• Sex workers found
easier to access services
• Opportunity for
increased contact and
understanding
Swathi Mahila Sangha &
partners, Bangalore, India
• Ensuring Dignity and
Rights among Sex
Workers in Bangalore
• Rose Campaign
– Hold up & ‘reward’
positive behavior
– Opened space for
dialogue
Resources
General Tools
• Challenging & Addressing
Stigma towards
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People living with HIV
Men who have sex with men
Sex workers
Drug users
• Guidance Documents
Health Care Specific
• Safe & Friendly Health Facility
Trainers Guide
(ISDS/ICRW/Horizons tools, Vietnam)
• Reducing Stigma and
Discrimination Related to HIV
and AIDS: Training for Health
Care Workers (Engender Health)
• Reducing HIV Stigma &
Gender Based Violence:
Toolkit for Health Care
Providers in India
(ICRW/BPWT/Levi Strauss Foundation)
• Global Stigma-Reduction
toolkit for health care settings
(Draft)
Stigma Action Network
‘Working for a World Free of
HIV-related Stigma’
www.stigmaactionnetwork.org
SAN Mission & Goals
‘To reduce HIVrelated stigma and
discrimination
through a dynamic
network that will
catalyze action and
commitment locally,
regionally and
globally through
knowledge sharing,
dialogue and
partnerships’
1. Bring together diverse
stakeholders to share
experiences, best practices,
knowledge, tools, and research
around HIV-related stigma and
discrimination.
2. Facilitate innovative solutions
and expand the reach of best
and promising practices to
reduce HIV-related stigma and
discrimination.
3. Promote research across
disciplines to expand the
evidence base for HIV-related
stigma and discrimination
reduction efforts
How can you participate?
• Join the network:
– Go to www.stigmaactionnetwork.org
– Click on the ‘Join Us’ link in the top right-hand corner and
register
– Log-in to the site and create your member profile and
organization profile
• Share materials & resources for posting on web site
– Upload documents, weblinks and events via the
CONTRIBUTE box
– Post to the SAN blog
– Participate in the discussion forum
• Participate in our upcoming e-survey
– Share your ideas about how best to expand the website
– Forthcoming in August, 2011
Hue Now
• Public & media
figure- a national
inspiration
– Time magazine
Asia hero, 2004
• Hoa Phuong
(Flamboyant Flower)
Time Asia
“Being involved in various activities of ISDS I felt great relief… I no longer wanted to hide
my positive status. The disclosure helped me to overcome self-stigma and it was a
magic medicine that made me confident and strong.”
Thank You!
www.healthpolicyproject.com
The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International
Development (USAID) under Cooperative Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is
implemented by Futures Group, the Centre for Development and Population Activities (CEDPA), Futures Institute,
Partners in Population and Development Africa Regional Office (PPD ARO), Population Reference Bureau (PRB),
Research Triangle Institute (RTI) International, and the White Ribbon Alliance for Safe Motherhood (WRA)