A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries

Willingness to seek medical care for tuberculosis and associated factors among the elderly population in Shenzhen: a cross-sectional study

OBJECTIVES

This study was aimed to assess the willingness of elderly people to seek medical care for tuberculosis (TB) and the associated influencing factors.

DESIGN

A cross-sectional study.

SETTING

A multistage random survey was conducted in Bao'an District of Shenzhen in China.

PARTICIPANTS

A total of 1200 elderly people aged 65 or above were recruited for the study and completed a structured questionnaire between September and October 2019.

MAIN OUTCOME MEASURES

Descriptive and binary logistic stepwise regression analyses were conducted to analyse the characteristics of elderly individuals, their willingness to seek medical care for TB and associated factors.

RESULTS

Among the final 1123 respondents, 943 (84.0%) were willing to seek medical care if they discovered suspicious TB symptoms. Binary logistic stepwise regression analysis indicated that respondents whose family annual income per capita was 50 000-100 000¥ (OR=2.56, 95% CI: 1.44 to 4.54, p<0.01) and who had positive attitudes (≥3 scores: OR=3.10, 95% CI: 1.90 to 5.05, p<0.01) or practices (≥4 scores: OR=3.13, 95% CI: 1.82 to 5.39, p<0.01) towards TB were more willing to seek medical care for TB.

CONCLUSIONS

Willingness to seek medical care for TB in the elderly population can be improved according to the determinants.

Experiences of social stigma among patients tested positive for COVID-19 and their family members: a qualitative study

Background

Social stigma against persons infected with COVID-19 is not uncommon. This qualitative study aimed to explore the experience of social stigma among COVID-19 positive patients and their family members.

Method

This cross-sectional study was conducted between April to June 2020 in Malaysia. Patients who have recovered from COVID-19 for at least 1 month and their family members who were tested with negative results, Malaysian and aged 18–65 years old were purposively sampled. Cold call method was employed to recruit patients while their family members were recruited by their recommendations. Telephone interviews were conducted with the participants after obtaining their verbal consent.

Results

A total of 18 participants took part in this study. Three themes emerged from the interviews: (Ι) experience of stigmatization, (ΙΙ) perspective on disease disclosure, and (ΙΙΙ) suggestion on coping and reducing stigma. The participants expressed their experiences of being isolated, labelled, and blamed by the people surrounding them including the health care providers, neighbours, and staff at the service counters. Some respondents expressed their willingness to share their experience with others by emphasizing the importance of taking preventive measure in order to stop the chain of virus transmission and some of them chose to disclose this medical history for official purpose because of fear and lack of understanding among the public. As suggested by the respondents, the approaches in addressing social stigma require the involvement of the government, the public, health care provider, and religious leader.

Conclusion

Individuals recovered from COVID-19 and their families experienced social stigma. Fear and lack of public understanding of the COVID-19 disease were the key factors for non-disclosure. Some expressed their willingness to share their experience as they perceived it as method to increase public awareness and thereby reducing social stigma. Multifaceted approaches with the involvement of multiple parties including the government, non-governmental organization as well as the general public were recommended as important measures to address the issues of social stigma.

Psychometric performance of the perceived stigma of substance abuse scale (PSAS) among patients on methadone maintenance therapy in Vietnam

BACKGROUND

People who inject drugs (PWID) and patients on methadone maintenance therapy (MMT) face severe stigma and discrimination. However, there are limited measures assessing stigma towards individuals with substance use disorders or MMT patients, particularly in Vietnam, and few studies have examined the psychometric properties of existing measures. This study aims to examine the performance of the eight-item Perceived Stigma of Substance Abuse Scale (PSAS), created in the United States, among a population of MMT patients in Vietnam.

METHODS

A cross-sectional survey was conducted among 400 adult patients enrolled in an urban MMT clinic. Substance use stigma was measured using the PSAS. We conducted confirmatory factor analysis (CFA) and assessed construct validity, reliability and known-group validity.

RESULTS

The original eight-item scale was unidimensional, but yielded mixed goodness-of-fit indicators. Ultimately, dropping two items and allowing the errors of the items related to childcare to correlate improved the goodness-of-fit indicators. (RMSEA = 0.025; CFI = 0.999; and SRMR = 0.018). The shortened scale demonstrated acceptable reliability (Cronbach's α = 0.766). The mean stigma scores were significantly higher among individuals not working, but did not significantly vary by length of time in MMT, marital status, education attainment, HIV status, depression, concurrent injection drug use or missed methadone dose.

CONCLUSIONS

The shortened six-item scale demonstrated good construct validity and acceptability reliability, but it did not demonstrate many a priori hypothesized known-group validity associations. Further research should consider a mixed-methods validation approach.

Surviving COVID-19 is Half the Battle; Living Life with Perceived Stigma is Other Half: A Cross-Sectional Study

BACKGROUND

Year 2020 started with global health crisis known as COVID-19. In lack of established tools and management protocols, COVID-19 had become breeding ground for fear and confusion, leading to stigma toward affected individuals.

METHOD

A cross-sectional study was conducted to estimate prevalence of stigma in discharged COVID-19 patients from a COVID hospital in India. Participants were approached telephonically using a semistructured questionnaire to record their experiences. Questions were asked regarding stigma at six major domains of daily life. Among total 1,673 discharged participants, 600 were conveniently selected and out of them 311 responded on telephonic interviews.

RESULT

We found that 182 (58.52%) participants (95% CI: 53.04-64.00) have self-perceived stigma, 163 (52.41%) participants (95% CI: 46.86-57.96) experienced quarantine-related stigma, 222 (71.38%) participants (95% CI: 66.36-76.40) experienced neighborhood stigma, 214 (68.81%) participants (95% CI: 63.66-73.95) experienced stigma while going out in marketplaces, 180 (57.88%) participants (95% CI: 52.39-63.37) experienced stigma at their work place, and 207 (66.56%) participants (95% CI: 61.31-71.80) reported stigma experienced by their family members. With a total of 84.5% (95% CI: 80.06-88.39) participants experiencing stigma at some domain and about 42.8% of participants facing stigma at all six domains. The commonest noted cause of stigma was fear of getting infected, reported by 184 (59.2%) participants.

CONCLUSION

This study shows high prevalence of stigma in COVID-19 patients suffering in their common domains of daily lives.

Breaking Down Barriers to HIV Care for Gay and Bisexual Men and Transgender Women: The Advocacy and Other Community Tactics (ACT) Project

Despite the prevailing consensus on the role that stigma and discrimination play in limiting access to HIV prevention technology, discouraging HIV testing, and impeding access to HIV care, studies that focus on structural interventions to address stigma and discrimination for gay, bisexual, and other men who have sex with men and transgender women are surprisingly uncommon. We aimed to identify the outcomes from a coordinated set of community-led advocacy initiatives targeting structural changes that might eliminate barriers to HIV care for gay and bisexual men and transgender women in five African and two Caribbean countries. We conducted a prospective evaluation that included repeated site visits and in-depth semi-structured interviews with 112 people with direct knowledge of project activities, accomplishments, failures, and challenges. Using outcome harvesting and qualitative analysis methods, we observed that over the 18-month implementation period, local advocacy efforts contributed to enhanced political will on the part of duty bearers for ensuring equitable access to HIV care, increases in the availability of affirming resources, improved access to existing resources, and changes in normative institutional practices to enable access to HIV care. Evidence on Project ACT points to the vital role community-led advocacy plays in addressing stigma and discrimination as structural barriers to HIV care.

Job Demands and Negative Outcomes after the Lockdown: The Moderating Role of Stigma towards Italian Supermarket Workers

The Job Demands-Resources model hypothesises that some variables (especially personal and social resources/threats) moderate the relationship between job demands and work outcomes. Based on this model, in this study we examine the role of stigma towards customers as a moderator of the relationship between job demands and a series of work outcomes: that is, fatigue, burnout, and satisfaction. We advance that the relationships between work demands and outcomes should be influenced by the employee’s perceptions regarding resources and constraint. In particular, we hypothesised that social stigma towards customers can represent a reliable moderating variable. Hypotheses were tested among 308 Italian supermarket workers in five supermarkets in the same chain, just after the end of the Italian lockdown caused by COVID-19. Results showed that stigma towards customers moderates the relationship between job demands and the consequences on the professional quality of life. The implications of these findings for the JD-R model are discussed.

Validation of an adapted instrument to measure female genital fistula-related stigma

Female genital fistula results in severe physical, psychological, and social sequelae. Qualitative research confirms stigma pervasiveness; however, no quantitative instrument exists to measure fistula-related stigma. We adapted an existing HIV-related stigma instrument to fistula-related stigma and assessed its reliability and validity. We recruited 60 Ugandan women seeking genital fistula surgery (December 2014-June 2015). We used exploratory factor analysis to explore the scale's latent structure and evaluated internal consistency reliability with Raykov's ρ statistic. We assessed construct validity through linear regression of stigma with quality of life, depressive symptoms and self-esteem. We retained 15 items across factors 'enacted stigma' and 'internalised stigma' (ρ = 0.960 and ρ = 0.748, respectively). Stigma was inversely associated with all quality of life domains; effect sizes were largest for environmental (enacted stigma, 0.69-point reduction) and psychological (internalised stigma, 0.67-point reduction) domains. Both stigma domains were associated positively with depressive symptoms and inversely with self-esteem, with 0.75 and 1.05-point increases in depressive symptoms and 0.45 and 0.77-point decreases in self-esteem for enacted and internalised stigma, respectively. Results suggest the reliability and validity of the adapted fistula stigma instrument. This instrument may help us understand stigma levels, compare stigma across individuals and communities, prioritise stigma-reduction strategies, and assess intervention impact.

Long-Distance Travel for HIV-Related Care-Burden or Choice?: A Mixed Methods Study in Tanzania

Decentralization of HIV care across sub-Saharan Africa has increased access to anti-retroviral therapy (ART). Although traveling for care has traditionally been viewed as a barrier, some individuals may choose to travel for care due to stigma and fear of HIV status disclosure. We sought to understand the prevalence of traveling long distances for HIV care, as well as reasons for engaging in such travel. Using a concurrent embedded mixed-methods study design, individuals receiving care at two HIV care and treatment clinics in Tanzania completed a quantitative survey (n = 196), and a sub-set of participants reporting long-distance travel for care were interviewed (n = 31). Overall 58.2% of participants (n = 114/196) reported knowing of a closer clinic than the one they chose to attend. Having experienced enacted stigma was significantly associated with traveling for care (OR 2.31, 95% CI 1.12, 4.75, p = 0.02). Reasons for clinic choice centered on three main themes: clinic familiarity, quality of care, and stigma. Traveling for care was often viewed as an enabling strategy for remaining engaged in care by helping overcome other barriers, including stigma and suboptimal quality of care.

COVID-19 Experiences and Social Distancing: Insights From the Theory of Planned Behavior

Purpose:

The objective of this study is to identify the relationship between COVID-19 experiences, perceived COVID-19 behavioral control, social norms and attitudes, and future intention to follow social distancing guidelines.

Design:

This is a cross-sectional study.

Setting:

Participants responded to an on-line survey in June 2020.

Subjects:

The study included 3,183 residents within Quebec, Canada aged 18 and over.

Measures:

Measures include perceived COVID-19 related discrimination, fear of COVID-19 infection, prior exposure to COVID-19, and prior social distancing behavior. Participants self-reported attitudes, perceived behavioral control, and perceived norms related to social distancing. Finally, we measured social distancing behavioral intention.

Analysis:

We evaluated a theory of planned behavior (TPB) measurement model of social distancing using confirmatory factor analysis (CFA). The association between COVID-19 perceived discrimination, fear of infection, previous social distancing behavior, exposure to COVID-19, TPB constructs and behavioral intentions to social distance were estimated using SEM path analysis.

Results:

TPB constructs were positively associated with intention to follow social distancing guidelines. Fear of COVID-19 infection and prior social distancing behavior were positively associated with behavioral intentions. In contrast, perceived discrimination was negatively associated with the outcome. Associations between fear of COVID-19, perceived COVID-19 discrimination and behavioral intentions were partially mediated by constructs of TPB.

Conclusions:

COVID-19 prevention efforts designed to emphasize positive attitudes, perceived control, and social norms around social distancing should carefully balance campaigns that heighten fear of infection along with anti- discrimination messaging.

A Review of the State of the Science of HIV and Stigma: Context, Conceptualization, Measurement, Interventions, Gaps, and Future Priorities

ABSTRACT

Stigma is a fundamental cause of health inequities. As such, stigma is a major barrier to HIV prevention, care, and treatment. This review will examine the concept of stigma, explicating the mechanisms of action of HIV-related stigma while also examining intersectional stigma and structural stigma. Instruments to measure HIV-related stigma and its mechanisms of action, as well as stigma enacted and experienced by HIV health care providers, will also be reviewed. This article will conclude with a review of stigma interventions, gaps in the literature, and priorities for future HIV, intersectional, and structural stigma research.

An Asynchronous Curriculum to Address Substance Use Disorder Training Needs for Medical and Surgical Residents

Developing substance use (SU) skills in medical training remains a challenge. Residents in teaching hospitals bear a large burden in managing SU sequelae and often lack support. Preventive and addiction medicine faculty defined broadly applicable core knowledge and skills for residents across specialties in a tertiary care center. Three 1-hour online modules were developed and delivered asynchronously to interns, followed by a live skills session at orientation. Topics were (1) Unhealthy SU Screening, Detection, and Intervention; (2) Bias and Communication; and (3) Safer Prescribing in Acute Pain. All 68 interns completed the curriculum. Pre/posttesting showed increased knowledge (52%-83% correct, P < .001) and perceived confidence (10-12.9, maximum 16, P < .001). Attitudes were unchanged (18.4-18.7, maximum 20, P = .07). This process identified and improved core knowledge and skills for SU prevention and treatment in medical and surgical trainees.

Impact of the COVID-19 pandemic on anxiety and depression symptoms of young people in the global south: evidence from a four-country cohort study

OBJECTIVE

To provide evidence on the effect of the COVID-19 pandemic on the mental health of young people who grew up in poverty in low/middle-income countries (LMICs).

DESIGN

A phone survey administered between August and October 2020 to participants of a population-based longitudinal cohort study established in 2002 comprising two cohorts born in 1994-1995 and 2001-2002 in Ethiopia, India (Andhra Pradesh and Telangana), Peru and Vietnam. We use logistic regressions to examine associations between mental health and pandemic-related stressors, structural factors (gender, age), and lifelong protective/risk factors (parent and peer relationship, wealth, long-term health problems, past emotional problems, subjective well-being) measured at younger ages.

SETTING

A geographically diverse, poverty-focused sample, also reaching those without mobile phones or internet access.

PARTICIPANTS

10 496 individuals were approached; 9730 participated. Overall, 8988 individuals were included in this study; 4610 (51%) men and 4378 (49%) women. Non-inclusion was due to non-location or missing data.

MAIN OUTCOME MEASURES

Symptoms consistent with at least mild anxiety or depression were measured by Generalized Anxiety Disorder-7 (≥5) or Patient Health Questionnaire-8 (≥5).

RESULTS

Rates of symptoms of at least mild anxiety (depression) were highest in Peru at 41% (32%) (95% CI 38.63% to 43.12%; (29.49-33.74)), and lowest in Vietnam at 9% (9%) (95% CI 8.16% to 10.58%; (8.33-10.77)), mirroring COVID-19 mortality rates. Women were most affected in all countries except Ethiopia. Pandemic-related stressors such as health risks/expenses, economic adversity, food insecurity, and educational or employment disruption were risk factors for anxiety and depression, though showed varying levels of importance across countries. Prior parent/peer relationships were protective factors, while long-term health or emotional problems were risk factors.

CONCLUSION

Pandemic-related health, economic and social stress present significant risks to the mental health of young people in LMICs where mental health support is limited, but urgently needed to prevent long-term consequences.

Knowledge, Attitudes, and Practices Related to COVID-19 Among Malawi Adults: A Community-Based Survey

Introduction: It is well-recognized that containing COVID-19 successfully is determined by people’s prevention measures which are related to their knowledge, attitudes, and practices (KAP). This perception has attracted attention in low- and middle-income countries (LMIC) due to their fragile health systems and economies. The objective of this study was to understand how residents in Malawi perceived COVID-19, to determine the factors related to KAP. Methods: A semi-structured questionnaire was used for the data collection. A field-based survey was conducted among adult residents in Lilongwe, Malawi. Descriptive statistic, linear regression, the Chi-square test, and Pearson’s correlation statistics were used for data analysis. Results: A total of 580 questionnaires were involved. The mean knowledge, attitude, and practice (KAP) scores were 10 (SD = ±3, range: 3–19), 16 (SD = ±4, range: 5–25), and 2 (SD = ±1, range: 0–5), respectively. Lack of money and resources (39%) was the biggest challenge for people who practice prevention measures. Among the participants, the radio (70%) and friends/family (56%) were the main sources of information. A higher economic status was associated with better KAP. Conclusions: A low level of KAP was detected among the population. The people faced challenges regarding a lack of necessary preventive resources and formal information channels. The situation was worse considering vulnerable population who had low economic status. Further all-round health education is urgently needed along with providing adequate health supplies and ensuring proper information management.

Predictors of Depressive Symptoms and Post Traumatic Stress Disorder Among Women Engaged in Commercial Sex Work in Southern Uganda

This study examined the factors associated with depressive symptoms and post traumatic depressive disorder (PTSD) among economically vulnerable women engaged in commercial sex work (WESW) in southern Uganda. Baseline data from a longitudinal cluster randomized study involving 542 self-identified WESW (18-55 years), recruited from 19 HIV hotspots were analyzed. Hierarchical linear regression modelling was utilized to estimate individual, family-level and economic-level predictors of depressive symptoms and PTSD. Family cohesion, sex work stigma, HIV status, financial distress, household assets, number of children and number of household income earners, were associated with PTSD. Similarly, family cohesion, number of people in the household, HIV status, sex work stigma, financial distress, and household assets, were associated with depressive symptoms. Women engaged in commercial sex work are at a higher risk of HIV and poor mental health outcomes. Sex work stigma and financial distress elevate levels of depressive symptoms and PTSD, over and above an individual's HIV status. Family and economic-level factors have the potential to mitigate the risk of poor mental health outcomes. As such, integrating stigma reduction and economic strengthening components in the programming targeting WESW-a key population, may be critical to address their mental health outcomes.

Behavioural responses and anxiety symptoms during the coronavirus disease 2019 (COVID-19) pandemic in Japan: A large scale cross-sectional study

BACKGROUND

This study explored the behavioural responses and anxiety symptoms of the general adult population in Japan during the ongoing coronavirus disease 2019 (COVID-19) outbreak.

METHODS

A web-based cross-sectional survey was conducted between 12th and May 13, 2020. Quota sampling was used to attain equal gender and age distributions representative of the Japanese population.

RESULTS

A total of 4127 complete responses were analysed. Higher educational level (B = 0.045, p = 0.002) and household income (B = 0.04, p = 0.009) were associated with a higher increase in preventive measures when comparing before and after the state of emergency was declared. The highest reported social anxiety was a feeling of fear (65.6%), followed by embarrassment (43.8%), keeping infection a secret (41.3%), avoidance (41.3%), and stigma (25.5%). A total of 86.1% of the respondents reported moderate to severe anxiety. The partial least square-based structural equation modelling (PLS-SEM) revealed that being female has the greatest effect (B = 0.246, p < 0.0001) on higher current preventive measures, followed by social anxiety (B = 0.119; p = 0.001) and State-Trait Anxiety Inventory scores (B = 0.153; p < 0.001). Perceived susceptibility (B = 0.033, p = 0.020), knowing someone who have been diagnosed with COVID-19 (B = 0.097, p < 0.001), higher income (B = 0.079, p < 0.001) and educational level (B = 0.045; p = 0.004) all had a small but significant effect on influencing levels of preventive measures.

CONCLUSIONS

A moderate level of preventive practices found in this study indicates the need to encourage behavioural change to limit the spread of the coronavirus. The provision of mental health services is warranted as anxiety symptoms are prevalent.

Akwenda intervention programme for children and youth with cerebral palsy in a low-resource setting in sub-Saharan Africa: protocol for a quasi-randomised controlled study

INTRODUCTION

Cerebral palsy (CP) is the most common childhood-onset motor disorder accompanied by associated impairments, placing a heavy burden on families and health systems. Most children with CP live in low/middle-income countries with little access to rehabilitation services. This study will evaluate the Akwenda CP programme, a multidimensional intervention designed for low-resource settings and aiming at improving: (1) participation, motor function and daily activities for children with CP; (2) quality of life, stress and knowledge for caregivers; and (3) knowledge and attitudes towards children with CP in the communities.

METHODS

This quasi-randomised controlled clinical study will recruit children and youth with CP aged 2-23 years in a rural area of Uganda. Children will be allocated to one of two groups with at least 44 children in each group. Groups will be matched for age, sex and motor impairment. The intervention arm will receive a comprehensive, multidimensional programme over a period of 11 months comprising (1) caregiver-led training workshops, (2) therapist-led practical group sessions, (3) provision of technical assistive devices, (4) goal-directed training and (5) community communication and advocacy. The other group will receive usual care. The outcome of the intervention will be assessed before and after the intervention and will be measured at three levels: (1) child, (2) caregiver and (3) community. Standard analysis methods for randomised controlled trial will be used to compare groups. Retention of effects will be examined at 12-month follow-up.

ETHICS AND DISSEMINATION

The study has been approved by the Uganda National Council for Science and Technology (SS 5173) and registered in accordance with WHO and ICMJE standards. Written informed consent will be obtained from caregivers. Results will be disseminated among participants and stakeholders through public engagement events, scientific reports and conference presentations.

TRIAL REGISTRATION NUMBER

Pan African Clinical Trials Registry (PACTR202011738099314) Pre-results.

Psychometric evaluation of a new drug-resistant tuberculosis stigma scale

OBJECTIVES

Stigma contributes to diagnostic delay, disease concealment, and reduced wellbeing for people with multidrug-resistant tuberculosis (MDR-TB) and their communities. Despite the negative effects of stigma, there are no scales to measure stigma in people with MDR-TB. This study aimed to develop and validate a scale to measure stigma in people affected by MDR-TB in Vietnam.

STUDY DESIGN AND SETTING

People with rifampicin-resistant (RR)-MDR-TB who had completed at least 3 months of treatment were invited to complete a survey containing 45 draft stigma items. Data analysis included exploratory factor analysis, internal consistency, content, criterion and construct validity, and test-retest reliability.

RESULTS

A total of 315 people with RR/MDR-TB completed the survey. Exploratory factor analysis revealed a 14 item RR/MDR-TB stigma scale with four subscales, including guilt, social exclusion, physical isolation, and blame. Internal consistency and test-retest reliability were good (Cronbach's Alpha = 0.76, ICC = 0.92). Construct validity was adequate with moderate correlations with related constructs.

CONCLUSION

Our RR/MDR-TB Scale demonstrated good psychometric properties in Vietnam. This scale will assist in the measurement of stigma in people with RR/MDR-TB. It will also aid in the evaluation of stigma reduction interventions in people with RR/MDR-TB.

Treatment adherence mediates the relationship between HIV-related stigma and health-related quality of life

There is a strong association between HIV-related stigma (HS) and health-related quality of life among people living with HIV/AIDS, yet few studies, to date, have examined mediators of this link. This study examined the mediating role of antiretroviral medication adherence (MA) on association between HS and HRQoL. Respondents were 969 people living with HIV/AIDS (PLWH) (628 males and 341 females, Mean age = 35.55, years), conveniently drawn from four hospital facilities in Enugu and Ebonyi States of Nigeria. Data were collected using HIV Stigma Scale, Morisky Medical Adherence Scale, and Patient Reported Outcome Quality of Life-HIV. Data were analysed using the Hayes PROCESS macro for SPSS which uses a regression-based, path-analytical framework. Results showed that HS across dimensions (personalised stigma, disclosure concern, concern about people's attitude and negative self-image) were negatively associated with MA (r = -.16; p < .001, r = -.13; p < .00, r = -.22; p < .001 and r = -.21; p < .001, respectively) HRQoL. MA was positively associated with HRQoL (r = . 24; p < .001). MA mediated HS-HRQoL association. These findings suggest that stigma associated with HIV/AIDS is associated with poor adherence to active antiretroviral therapy (ART) treatment regimen, which can result in poor health and treatment outcome among PLWH. The findings may be helpful in improving HRQoL among PLWH.

Travel time to health-care facilities, mode of transportation, and HIV elimination in Malawi: a geospatial modelling analysis

BACKGROUND

UNAIDS has prioritised Malawi and 21 other countries in sub-Saharan Africa for fast-tracking the end of their HIV epidemics. UNAIDS' elimination strategy requires achieving a treatment coverage of 90% by 2030. However, many individuals in the prioritised countries have to travel long distances to access HIV treatment and few have access to motorised transportation. Using data-based geospatial modelling, we investigated whether these two factors are barriers to achieving HIV elimination in Malawi and assessed the effect of increasing bicycle availability on expanding treatment coverage.

METHODS

We built a data-based geospatial model that we used to estimate the minimum travel time needed to access treatment, for every person living with HIV in Malawi. We constructed our model by combining a spatial map of health-care facilities, a map that showed the number of HIV-infected individuals per km², and an impedance map. We quantified impedance using data on road and river networks, land cover, and topography. We estimated travel times for the existing coverage of 70%, and the time that HIV-infected individuals would need to spend travelling in order to achieve a coverage of 90%, whether driving, bicycling, or walking.

FINDINGS

We identified a quantitative relationship between the maximum achievable coverage of treatment and the minimum travel time to the nearest health-care facility. At 70% coverage, health-care facilities can be reached within approximately 45 min if driving, 65 min if bicycling, and 85 min if walking. Increasing coverage above 70% will become progressively more difficult. To reach 90% coverage, many HIV-infected individuals (who have yet to initiate treatment) will need to travel for almost twice as long as those already on treatment. Bicycling, rather than walking, in rural areas would substantially increase the maximum achievable coverage.

INTERPRETATION

The long travel times needed to reach health-care facilities coupled with little motorised transportation in rural areas are substantial barriers to reaching 90% coverage in Malawi. Increased bicycle availability could help eliminate HIV.

FUNDING

US National Institute of Allergy and Infectious Diseases.

Ethno-cultural disparities in mental health during the COVID-19 pandemic: a cross-sectional study on the impact of exposure to the virus and COVID-19-related discrimination and stigma on mental health across ethno-cultural groups in Quebec (Canada)

BACKGROUND

Although social and structural inequalities associated with COVID-19 have been documented since the start of the pandemic, few studies have explored the association between pandemic-specific risk factors and the mental health of minority populations.

AIMS

We investigated the association of exposure to the virus, COVID-19-related discrimination and stigma with mental health during the COVID-19 pandemic, in a culturally diverse sample of adults in Quebec (Canada).

METHOD

A total of 3273 residents of the province of Quebec (49% aged 18-39 years, 57% women, 51% belonging to a minority ethno-cultural group) completed an online survey. We used linear and ordinal logistic regression to identify the relationship between COVID-19 experiences and mental health, and the moderating role of ethno-cultural identity.

RESULTS

Mental health varied significantly based on socioeconomic status and ethno-cultural group, with those with lower incomes and Arab participants reporting higher psychological distress. Exposure to the virus, COVID-19-related discrimination, and stigma were associated with poorer mental health. Associations with mental health varied across ethno-cultural groups, with exposed and discriminated Black participants reporting higher mental distress.

CONCLUSIONS

Findings indicate sociocultural inequalities in mental health related to COVID-19 in the Canadian context. COVID-19-related risk factors, including exposure, discrimination and stigma, jeopardise mental health. This burden is most noteworthy for the Black community. There is an urgent need for public health authorities and health professionals to advocate against the discrimination of racialised minorities, and ensure that mental health services are accessible and culturally sensitive during and in the aftermath of the pandemic.

Perceived stigma among patient with pulmonary tuberculosis at public health facilities in southwest Ethiopia: A cross-sectional study

OBJECTIVES

Although tuberculosis (TB) related stigma has a significant impact on the diagnosis, patient adherence with treatment, and recovery from the disease, there is limited evidence from Ethiopia regarding perceived stigma among patient with pulmonary tuberculosis (PTB).The purpose of this study was to assess perceived stigma and associated factors among patient with PTB on treatment in southwest Ethiopia.

METHODS

Institution-based cross-sectional study was conducted from April to May 2019 among 410 patient with PTB. Data were collected by using the perceived tuberculosis stigma scale. Epi data v3.1 and SPSSv23 were used for data entry and analysis. Multivariable logistic regression models were fitted to identify factors associated with perceived stigma. Results are presented as adjusted odds ratios (AORs) with 95% confidence intervals (CIs).

RESULT

Prevalence of perceived stigma among patient with Pulmonary tuberculosis was 57.1% (95% CI: 52.2, 61.7). Poor social support (AOR = 2.41; 95% CI: 1.06, 5.48), above a month duration of illness (AOR = 2.48; 95% CI: 1.33, 4.64), high perceived stress (AOR = 1.95; 95% CI:1.09, 3.49), current khat use (AOR = 1.88; 95% CI:1.05, 3.37), and presence of depression (AOR = 8.18; 95% CI:4.40, 15.22) were significantly associated with perceived stigma. Patient with HIV co-infection were 5.67 times (AOR = 5.67; 95% CI: 2.32, 13.87) more likely to have Perceived stigma than their counterparts.

CONCLUSION

TB related stigma was reported by more than half of the study participant. Stigma reduction measures are needed to lower TB related stigma perceived by the patient, the level of distress associated with it, and to promote the psychological wellbeing of patient with TB.

"It's because I think too much": Perspectives and experiences of adults with hypertension engaged in HIV care in northern Tanzania

Background

Hypertension, a leading risk for cardiovascular mortality, is an important co-morbidity among people living with HIV (PLHIV). In Tanzania, hypertension prevalence among PLHIV approaches 20 to 30%. However, most patients are unaware of their diagnosis and are not receiving treatment. Understanding the barriers to hypertension care is a critical first step in developing interventions to improve cardiovascular outcomes among PLHIV in Tanzania and similar settings.

Methods

Between September 1^st and November 26^th, 2018 thirteen semi structured in-depth interviews were conducted with hypertensive patients engaged in HIV care in two HIV clinics located in government health facilities in northern Tanzania. Interviews were audio-recorded, translated into English, transcribed and thematically coded using NVivo. Data analysis was conducted using applied thematic analysis.

Results

Participants had a median age of 54 (IQR 41–65) years. Of the 13 participants, eight stated they had used antihypertensive medication previously, but only one participant described current use of antihypertensive therapy. All participants were currently using antiretroviral therapy. The data revealed a range of themes including limited hypertension knowledge. Universally, all participants believed that “thinking too much”, i.e. stress, was the major contributor to hypertension and that by “reducing thoughts”, one may control hypertension. Additional emerging themes included a perceived overlap between hypertension and HIV, delays in hypertension diagnosis and linkage to care, challenges with provider communication and counseling, reluctance towards antihypertensive medication, lack of integration of hypertension and HIV care, and additional structural barriers to hypertension care.

Conclusions

Participants described multiple, intersecting challenges related to hypertension management. Barriers specific to PLHIV included siloed care, HIV-related stigma, and burden from multiple medical conditions. Multifaceted strategies that seek to address structural barriers, hypertension education, psychosocial stressors and stigma, and that are integrated within HIV care are urgently needed to improve cardiovascular outcomes among PLHIV in sub-Saharan Africa.

Police Discrimination, Misconduct, and Stigmatization of Female Sex Workers in Kenya: Associations with Delayed and Avoided Health Care Utilization and Lower Consistent Condom Use

Discrimination and violence against sex workers by police are common in many populations and are associated with negative health outcomes, as well as being per se violations of human rights laws and norms. There is a close and mutually reinforcing nexus between legally actionable rights violations and stigma, and reducing human rights violations against sex workers likely requires both legal and societal interventions that address both. In this paper, we first aim to estimate levels of discrimination, violence, and stigma against women sex workers by police in Kenya. Second, we aim to estimate the association between manifestations of discrimination and stigma, on the one hand, and general health care utilization and consistent condom use, on the other. Using data from a survey of Kenyan sex workers, we document widespread discrimination and stigma. Through regression analyses, participants with the highest levels of all three categories of manifestations of discrimination and stigma reported significant lower consistent condom use. Those with the highest levels of witnessed/heard manifestations were significantly more likely to delay or avoid needed health care, and the highest level of experienced manifestations were associated with a marginally significant increase in delay or avoidance. Our findings document a plethora of violations of human rights obligations under Kenyan and international law.

Australian and Indian nursing students' skills and attitudes surrounding mental illness: Preparing for a transnational nursing education collaboration

Cultural competence is a viewed as a necessary set of skills within nursing, and there is a need for student support in this area. This is particularly important in mental health care, with two skills considered crucial for providing quality care: therapeutic relationship skills and positive attitudes. With the objective of initiating an educational collaboration between two educational institutions, this study examined Australian and Indian undergraduate nursing student's perceived therapeutic relationship skills and stigma attitudes associated with mental illness. Participants were five hundred and fifty-five (n = 555) undergraduate nursing students from two different universities in Indian and Australia. The modified version of the Scale To Assess Therapeutic Relationship (STAR-C) and the Social Distance Scale (SDS) were both used to examine student's perceived therapeutic relationship skills and stigma attitudes. Australian nursing students indicated lower levels of stigma with lower levels of self-reported therapeutic relationships skills, as compared with the Indian nursing student cohort. However, Indian nursing students indicated higher levels of stigma with higher self-reported therapeutic relationship skills. The results of this study may reflect cultural differences and meanings attached to mental illness.

Comparing and Predicting Public Attitudes Toward Stuttering, Obesity, and Mental Illness

Purpose Extensive research on public attitudes has documented stigma toward stuttering, obesity, and mental illness; however, most studies have focused on only one of these conditions. This study sought to compare public attitudes toward stuttering, obesity, and mental illness as well as to identify the predictive potential of four ratings relating to these and other neutral or desirable conditions. Method Five hundred respondents who were selected from each of three international databases filled out the Public Opinion Survey of Human Attributes (POSHA) for stuttering, obesity, or mental illness. The POSHA surveys were as similar as possible, and all contained four general items asking respondents' "impression" of the attribute, extent to which he or she "wants to be/have" that attribute, "amount known" about the attribute, and "persons known" who manifest the attribute, for stuttering, obesity, and mental illness plus two others, namely, left-handedness and intelligence. The POSHA surveys also had the same summary scores, Beliefs, Self-Reactions, and an Overall Score. Results Summary scores for the three POSHA surveys in the 500-respondent samples revealed negative attitudes toward all three conditions, the most positive being toward obesity, followed by stuttering and then by mental illness. Stepwise regression analysis indicated that various general items had significant prediction potential not only of attitudes for the same condition but also of attitudes for other conditions. The greatest other condition predictions were between stuttering and mental illness. Conclusions Stuttering is regarded as less stigmatizing than mental illness but more stigmatizing than obesity. Additionally, positivity toward one condition results in limited positivity toward the others. Impressions and knowledge of-as well as experience with-stigmatized conditions can inform public awareness campaigns and individual clinical programs dealing with stigma. Supplemental Material https://doi.org/10.23641/asha.12860939.

A Qualitative Study: Hypertension Stigma Among Black Women

BACKGROUND

The prevalence of hypertension (HTN) in Blacks is among the highest in the world. For Black women, 46% experience stage 2 HTN (blood pressure [BP] ≥140/90 mm Hg) as compared with 42% of Black men. Because of higher rates of stage 2 HTN, Black women have greater rates of cardiovascular disease and stroke. For reasons unknown, nonadherence to lifestyle modifications and antihypertensive medications continues. An understudied potential factor associated with poor adherence to the treatment regimen and negative health outcomes is stigma.

OBJECTIVE

The aim of this study was to gain insight and describe the psychological factor of stigma as an influence on poorly controlled HTN in Black women.

METHODS

Hypertensive Black women attending a 6-week self-management program were invited to participate in an open-ended questionnaire. Six groups were held with 62 women aged 24 to 70 years, with group size ranging from 10 to 15. Women anonymously wrote their answer to 2 questions to capture individual responses without group persuasion. Data were analyzed using thematic analysis.

RESULTS

Five themes were generated inductively from the data and included (1) desire to get control, (2) shame and embarrassment, (3) obesity characterizations, (4) stereotype threats, and lastly, (5) disrupted normality. During member checking, younger participants were more vocal about stigma, whereas older participants did not view stigma as problematic.

CONCLUSIONS

Hypertension stigma could potentially deter adherence to high BP treatment. Further research is needed to explore the prevalence of stigma in this population and its impact on behaviors that hinder BP control.

Predictors of suicidal ideation among Iranian patients with multiple sclerosis

Background: Considering the high probability of suicidal behaviors in multiple sclerosis (MS) population of other countries and the unlikeliness of its diagnosis in patients with MS by specialists, the current research targets the frequency of suicidal thoughts and mood symptoms in a group of patients with MS in Iran. Also, we investigated the relationships among suicidal thoughts, anxiety, depression, anticipated stigma, social support, some disease characteristics, and sociodemographic factors. Methods: A sample of 276 subjects were selected from community-based MS clinics and referral out-patient MS clinic of Sina Hospital affiliated to Tehran University of Medical Sciences, Tehran, Iran. Participants completed the Patient Health Questionnaire (PHQ), the Hospital Anxiety and Depression Scale (HADS), the Chronic Illness Anticipated Stigma Scale (CIASS), the Multidimensional Scale of Perceived Social Support (MSPSS), and a personal information questionnaire. Results: 36.2% of the participants had suicidal thoughts. Suicidal ideation was significantly more likely among people who reported higher anxiety and depression scores or anticipated stigma from their friends and families. Women and patients with higher education experienced suicidal ideation more frequently than others. Conclusion: Findings regarding the comorbidity of suicidal thoughts with anticipated stigma, depression and anxiety in MS patients emphasizes therapeutic interventions focused on the alleviation of perceived stigma as well as mood symptoms.

Pandemic, panic, and psychiatrists - What should be done before, during, and after COVID-19?

• Causes and effects of psychological burden around COVID-19 pandemic. • Role of mental health professionals in various phases of pandemic progression. • Goals and objectives to utilize resources to battle with mental health aspects of COVID-19. • Cautious solutions to prevent a possible pandemic of mental-illnesses in aftermath of COVID-19.

Validation of an adapted instrument to measure female genital fistula-related stigma

Female genital fistula results in severe physical, psychological, and social sequelae. Qualitative research confirms stigma pervasiveness; however, no quantitative instrument exists to measure fistula-related stigma. We adapted an existing HIV-related stigma instrument to fistula-related stigma and assessed its reliability and validity. We recruited 60 Ugandan women seeking genital fistula surgery (December 2014-June 2015). We used exploratory factor analysis to explore the scale's latent structure and evaluated internal consistency reliability with Raykov's ρ statistic. We assessed construct validity through linear regression of stigma with quality of life, depressive symptoms and self-esteem. We retained 15 items across factors 'enacted stigma' and 'internalised stigma' (ρ = 0.960 and ρ = 0.748, respectively). Stigma was inversely associated with all quality of life domains; effect sizes were largest for environmental (enacted stigma, 0.69-point reduction) and psychological (internalised stigma, 0.67-point reduction) domains. Both stigma domains were associated positively with depressive symptoms and inversely with self-esteem, with 0.75 and 1.05-point increases in depressive symptoms and 0.45 and 0.77-point decreases in self-esteem for enacted and internalised stigma, respectively. Results suggest the reliability and validity of the adapted fistula stigma instrument. This instrument may help us understand stigma levels, compare stigma across individuals and communities, prioritise stigma-reduction strategies, and assess intervention impact.

Social stigma among tuberculosis patients attending DOTS centers in Delhi

Background:

Every year >9 million people suffer from tuberculosis (TB) and India accounts for >25% of global TB burden. Tuberculosis patients experience both psychological and social suffering. Amongst the problems met by tuberculosis patients, social stigma has been increasingly recognized. This study was done to assess social stigma and associated factors among the tuberculosis patients attending Directly Observed Treatment Short-course (DOTS) centers in South East Delhi.

Material and Methods:

It was a cross-sectional study carried out among tuberculosis patients availing treatment from DOTS centers of South East Delhi. Out of 48 DOTS centers in South East Delhi, 6 centers were selected on the basis of population proportion to size. A total of 270 TB patients were interviewed using a semi-structured, pretested questionnaire consisting of stigma-based questions. Fisher exact and Chi-square test applied.

Results:

The mean age of patients was 31.5 years (SD ± 11.5) with age ranging from 18 to 77 years. Males were higher (57.4%) compared to females (42.6%). 123 (45.5%) perceived stigma with family/friends and 92/158 (58.2%) perceived stigma at workplace. Young patients (<30 years), males faced more stigma at workplace and lower socioeconomic class faced higher stigma with family and friends (P < 0.05).

Conclusion:

There is still higher stigmatization faced by patients with TB at family/friends and at workplace. Motivation by friends/family and support at workplace has been crucial in achieving successful treatment outcomes.

Social stigma in the time of coronavirus disease 2019

The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the lives of people around the globe since it appeared in Wuhan, China, at the beginning of December 2019. The burden of disease and its death toll have had an unprecedented impact on the healthcare, economic and financial systems of low-, middle- and high-income countries [1–3]. Peoples’ lives have been disrupted and negatively impacted by COVID-19-related suffering and lockdowns at community and household level.

Addressing COVID-19-related stigmahttps://bit.ly/2CPuxO1

A systematic review of validated screening tools for anxiety disorders and PTSD in low to middle income countries

BACKGROUND

Anxiety and post-traumatic stress disorder (PTSD) contribute significantly to disability adjusted life years in low- to middle-income countries (LMICs). Screening has been proposed to improve identification and management of these disorders, but little is known about the validity of screening tools for these disorders. We conducted a systematic review of validated screening tools for detecting anxiety and PTSD in LMICs.

METHODS

MEDLINE, EMBASE, Global Health and PsychINFO were searched (inception-April 22, 2020). Eligible studies (1) screened for anxiety disorders and/or PTSD; (2) reported sensitivity and specificity for a given cut-off value; (3) were conducted in LMICs; and (4) compared screening results to diagnostic classifications based on a reference standard. Screening tool, cut-off, disorder, region, country, and clinical population were extracted for each study, and we assessed study quality. Accuracy results were organized based on screening tool, cut-off, and specific disorder. Accuracy estimates for the same cut-off for the same screening tool and disorder were combined via meta-analysis.

RESULTS

Of 6322 unique citations identified, 58 articles including 77 screening tools were included. There were 46, 19 and 12 validations for anxiety, PTSD, and combined depression and anxiety, respectively. Continentally, Asia had the most validations (35). Regionally, South Asia (11) had the most validations, followed by South Africa (10) and West Asia (9). The Kessler-10 (7) and the Generalized Anxiety Disorder-7 item scale (GAD-7) (6) were the most commonly validated tools for anxiety disorders, while the Harvard Trauma Questionnaire (3) and Posttraumatic Diagnostic Scale (3) were the most commonly validated tools for PTSD. Most studies (29) had the lowest quality rating (unblinded). Due to incomplete reporting, we could meta-analyze results from only two studies, which involved the GAD-7 (cut-off ≥10, pooled sensitivity = 76%, pooled specificity = 64%).

CONCLUSION

Use of brief screening instruments can bring much needed attention and research opportunities to various at-risk LMIC populations. However, many have been validated in inadequately designed studies, precluding any general recommendation for specific tools in LMICs. Locally validated screening tools for anxiety and PTSD need further evaluation in well-designed studies to assess whether they can improve the detection and management of these common disorders.

TRIAL REGISTRATION

PROSPERO registry number CRD42019121794 .

Validity, reliability and cut-offs of the Patient Health Questionnaire-9 as a screening tool for depression among patients living with epilepsy in Rwanda

BACKGROUND

Patients with epilepsy (PwE) have an increased risk of active and lifetime depression. Two in 10 patients experience depression. Lack of trained psychiatric staff in low- and middle-income countries (LMIC) creates a need for screening tools that enable detection of depression in PwE. We describe the translation, validity and reliability assessment of the Patient Health Questionnaire-9 (PHQ-9) as a screening tool for depression among PwE in Rwanda.

METHOD

PHQ-9 was translated to Kinyarwanda using translation-back translation and validated by a discussion group. For validation, PwE of ≥15 years of age were administered the PHQ-9 and Hamilton Depression Rating Scale (HDRS) by trained psychiatry staff at Visit 1. A random sample of 20% repeated PHQ-9 and HDRS after 14 days to assess temporal stability and intra-rater reliability. Internal structure, reliability and external validity were assessed using confirmatory factor analysis, reliability coefficients and HDRS-correlation, respectively. Maximal Youden's index was considered for cut-offs.

RESULTS

Four hundred and thirty-four PwE, mean age 30.5 years (SD ±13.3), were included of whom 33.6%, 37.9%, 13.4%, and 15.1% had no, mild, moderate and severe depression, respectively. PHQ-9 performed well on a one-factor model (unidimensional model), with factor loadings of 0.63-0.86. Reliability coefficients above 0.80 indicated strong internal consistency. Good temporal stability was observed (0.79 [95% CI: 0.68-0.87]). A strong correlation (R = 0.66, p = 0.01) between PHQ-9 and HDRS summed scores demonstrated robust external validity. The optimal cut-off for the PHQ-9 was similar (≥5) for mild and moderate depression and ≥7 for severe depression.

CONCLUSION

PHQ-9 validation in Kinyarwanda creates the capacity to screen PwE in Rwanda at scores of ≥5 for mild or moderate and ≥7 for severe depression. The availability of validated tools for screening and diagnosis for depression is a forward step for holistic care in a resource-limited environment.

Stigma and quality of co-located care for HIV-positive people in addiction treatment in Ukraine: a cross-sectional study

INTRODUCTION

Co-located treatment for HIV and opioid use disorder has been shown to improve care outcomes for HIV-positive people who inject drugs (PWID) in Ukraine. However, patients continue to be stigmatized for both HIV and substance use. This study aimed to assess whether co-located care for HIV-positive PWID receiving opioid agonist treatment (OAT) services in Ukraine is associated with less stigma and better perceived quality of HIV services.

METHODS

This cross-sectional study enrolled 191 HIV-positive PWID who received OAT services at three healthcare facilities providing substance use treatment (OAT only) and at four facilities that provided co-located care (both OAT and HIV treatment) in six regions in Ukraine during July-September, 2017. Primary outcomes were HIV stigma (Berger scale), substance use stigma (Substance Abuse Stigma Scale) and intersectional stigma (both stigma forms above 75th percentile). Secondary outcome was quality of HIV care, a composite score based on a package of received services. Linear and ordinal regressions were used to assess the predictors of selected outcomes.

RESULTS

Study participants were 75% male, mean age 40 ± 7 years; 47% received co-located care, and 10.5% had both high HIV and substance use stigma. Co-located care was neither associated with HIV nor substance use stigma but it was linked to better quality of HIV care (adjusted odds ratio: 4.13; 95% CI: 2.31, 7.54). HIV stigma was associated with suicide attempts (adjusted beta (aβ): 5.90; 95% CI: 2.05, 9.75), and substance use stigma was linked to poor mental health (aβ: -0.26; 95% CI: -0.44, -0.08) and lower likelihood of receipt of services from non-governmental organization (NGO; aβ: -6.40; 95% CI: -10.23, -2.57).

CONCLUSION

One in ten people with HIV in this cohort who received OAT services experienced high levels of both HIV and substance use stigma, which was associated with poorer mental health and less NGO support. Co-located HIV and OAT services were linked to better perceived quality of HIV care, but did not seem to reduce stigma for this key population. Stigma interventions for PWID, possibly delivered involving NGOs, may be an approach to mitigate this challenge.

Measuring Stigma to Assess the Social Justice Implications of Health-Related Policy Decisions: Application to Novel Treatment Regimens for Multidrug-Resistant Tuberculosis

In making policy decisions with constrained resources, an important consideration is the impact of alternative policy options on social justice. Social justice considers interactions between individuals and society and can be conceptualized across domains of agency, association, and respect. Despite its importance, social justice is rarely considered formally in health policy decision making, partially reflecting challenges in its measurement. We define three criteria for considering social justice in health-related policy decisions: 1) linkage of social justice to a measurable construct; 2) ability to reproducibly and feasibly estimate the impacts of a policy decision on the selected construct; and 3) appropriate presentation to decision makers of the expected social justice implications using that construct. We use preliminary data from qualitative interviews from three groups of respondents in South Africa and Uganda to demonstrate that stigma meets the first of these criteria. We then use the example of policy addressing novel treatment regimens for multidrug-resistant tuberculosis and a validated tuberculosis stigma scale to illustrate how policy effects on stigma could be estimated (criterion 2) and presented to decision makers in the form of justice-enhanced cost-effectiveness analysis (criterion 3). Finally, we provide a point-by-point guide for conducting similar assessments to facilitate consideration of social justice in health-related policy decisions. Our case study and guide for how to make social justice impacts more apparent to decision makers also illustrates the importance of local data and local capacity. Performing social justice assessments alongside more traditional evaluations of cost-effectiveness, budget impact, and burden of disease could help represent data-informed considerations of social justice in health care decision making more broadly.

Reducing mental illness stigma in healthcare settings: Proof of concept for a social contact intervention to address what matters most for primary care providers

Initiatives for integration of mental health services into primary care are underway through the World Health Organization's mental health Gap Action Programme (mhGAP) and related endeavors. However, primary healthcare providers' stigma against persons with mental illness is a barrier to success of these programs. Therefore, interventions are needed to reduce stigma among primary healthcare providers. We developed REducing Stigma among HealthcAre ProvidErs (RESHAPE), a theoretically-grounded intervention that draws upon the medical anthropology conceptual framework of "what matters most." RESHAPE addresses three domains of threats to what matters most: survival, social, and professional. In a proof-of-concept study, mental health service users and aspirational healthcare providers (primary healthcare providers actively incorporating mental health services) were trained to co-facilitate the RESHAPE intervention embedded within mhGAP training in Nepal. Two trainings with the RESHAPE anti-stigma component were held with 41 primary healthcare providers in Nepal. Evaluation of the training included four focus groups and 25 key informant interviews. Stigmatizing attitudes and role play-based clinical competency, assessed with the ENhancing Assessment of Common Therapeutic factors tool (ENACT), were evaluated pre-training and followed-up at four and 16 months. The study was conducted from February 2016 through June 2017. In qualitative interviews, primary healthcare providers described changes in perceptions of violence (survival threats) and the ability to treat mental illness effectively (professional threats). Willingness to interact with a person with mental illness increased from 54% pre-training to 81% at 16 months. Observed clinical competency increased from 49% pre-training to 93% at 16-months. This proof-of-concept study supports reducing stigma by addressing what matters most to healthcare providers, predominantly through mitigating survival and professional threats. Additional efforts are needed to address social threats. These findings support further exploration of service user and aspirational figure involvement in mhGAP trainings based on a "what matters most" conceptual framework.

Message framing to reduce stigma and increase support for policies to improve the wellbeing of people with prior drug convictions

BACKGROUND

Individuals with drug convictions are at heightened risk of poor health, due in part to punitive public policies. This study tests the effects of message frames on: (1) public stigma towards individuals with felony drug convictions and (2) support for four policies in the United States (U.S.) affecting social determinants of health: mandatory minimum sentencing laws, 'ban-the-box' employment laws, and restrictions to supplemental nutrition and public housing programs.

METHODS

A randomized experiment (n = 3,758) was conducted in April 2018 using a nationally representative online survey panel in the U.S. Participants were randomized to a no-exposure arm or one of nine exposure arms combining: (1) a description of the consequences of incarceration and community reentry framed in one of three ways: a public safety issue, a social justice issue or having an impact on the children of incarcerated individuals, (2) a narrative description of an individual released from prison, and (3) a picture depicting the race of the narrative subject. Logistic regression was used to assess effects of the frames.

RESULTS

Social justice and the impact on children framing lowered social distance measures and increased support for ban-the-box laws.

CONCLUSION

These findings can inform the development of communication strategies to reduce stigma and advocacy efforts to support the elimination of punitive polices towards individuals with drug convictions.

Longitudinal Analysis of Depressive Symptoms, Perceived Social Support, and Alcohol Use among HIV-Infected Men Who Inject Drugs in Northern Vietnam

Background: Limited research examines depressive symptoms, alcohol use, and social support among HIV-infected people who inject drugs. Objectives: Using longitudinal data, we investigated whether perceived social support moderates the relationship between depressive symptoms and alcohol use among HIV-infected men who inject drugs in Vietnam. Methods: Data were collected from participants (N = 455; mean age 35 years) in a four-arm randomized controlled trial in Thai Nguyen, Vietnam. Data were collected at baseline, 6, 12, 18, and 24 months with 94% retention excluding dead (N = 103) or incarcerated (N = 37) participants. Multilevel growth models were used to assess whether: (1) depressive symptoms predict when risk of alcohol use is elevated (within-person effects); (2) depressive symptoms predict who is at risk for alcohol use (between-person effects); and (3) within- and between-person perceived social support moderates the depressive symptoms-alcohol relationship. Results: Participants reported high but declining levels of depressive symptoms and alcohol use. Participants with higher depressive symptoms drank less on average (B = -0.0819, 95% CI -0.133, -0.0307), but within-person, a given individual was more likely to drink when they were feeling more depressed than usual (B = 0.136, 95% CI 0.0880, 0.185). The positive relationship between within-person depressive symptoms and alcohol use grew stronger at higher levels of within-person perceived social support. Conclusions: HIV-infected men who inject drugs have increased alcohol use when they are experiencing higher depressive symptoms than usual, while those with higher average depressive symptoms over time report less alcohol use. Social support strengthens the positive relationship between within-person depressive symptoms and alcohol use.

Health-Related Quality of Life and Associated Factors Among Adult HIV Mono-Infected and TB/HIV Co-Infected Patients in Public Health Facilities in Northeast Ethiopia: A Comparative Cross-Sectional Study

PURPOSE

This study was conducted to assess the health-related quality of life and associated factors among adult human immunodeficiency virus (HIV) mono-infected and tuberculosis (TB) and HIV co-infected patients in the public health facilities of northeast Ethiopia.

METHODS

A comparative facility-based cross-sectional study was conducted from February 01 to May 30, 2019. A total of 434 HIV mono-infected and 143 TB/ HIV co-infected patients were randomly selected for the study. The data were collected using an interviewer-administered structured questionnaire. The health-related quality of life of patients was measured using the World Health Organization quality of life HIV instrument which contains physical, psychological, social relationships, environmental, level of independence, and spiritual domains. The validated version of the Kessler scale was used to assess depressive symptoms. Linear regression analysis was performed to identify factors associated with the outcome variables, and a p-value < 0.05 with 95% CI was used to measure the degree of association between health-related quality of life and independent variables.

RESULTS

The mean scores of health-related quality of life among HIV mono-infected patients in terms of thephysical, psychological, level of independence, social relationships, environmental, and spiritual health domains were 63.9, 65.0, 60.5, 59.0, 56.4, and 63.9, respectively; whereas the mean scores among TB/HIV co-infected patients were 46.6, 48.5, 42.7, 43.5, 39.3, and 51.3, respectively. Among HIV mono-infected patients, being married improved the quality of social relationships by 6.7 compared with unmarried patients (β = 6.7, 95% CI = 3.24, 10.11); whereas among the TB/HIV co-infected patients, being educated increased the quality of social relationships by 10.6 compared with being uneducated (β=10.6, 95% CI=3.70, 17.51).

CONCLUSION

The study revealed that the TB/HIV co-infected patients had poor health-related quality of life in all domains compared with HIV mono-infected patients. Besides, depression and stigma were more prevalent among co-infected patients. Therefore, designing and implementing specific management that focuses on psychiatric centers for TB/HIV co-infected patients will be necessary as their quality of life is lowered.

Stigma reduction interventions for children and adolescents in low- and middle-income countries: Systematic review of intervention strategies

Stigmatisation and discrimination are common worldwide, and have profound negative impacts on health and quality of life. Research, albeit limited, has focused predominantly on adults. There is a paucity of literature about stigma reduction strategies concerning children and adolescents, with evidence especially sparse for low- and middle-income countries (LMIC). This systematic review synthesised child-focused stigma reduction strategies in LMIC, and compared these to adult-focused interventions. Relevant publications were systematically searched in July and August 2018 in the following databases; Cochrane, Embase, Global Health, HMIC, Medline, PsycINFO, PubMed and WorldWideScience.org, and through Google Custom Search. Included studies and identified reviews were cross-referenced. Three categories of search terms were used: (i) stigma, (ii) intervention, and (iii) LMIC settings. Data on study design, participants and intervention details including strategies and implementation factors were extracted. Within 61 unique publications describing 79 interventions, utilising 14 unique stigma reduction strategies, 14 papers discussed 21 interventions and 10 unique strategies involving children. Most studies targeted HIV/AIDS (50% for children, 38% for adults) or mental illness (14% vs 34%) stigma. Community education (47%), individual empowerment (15%) and social contact (12%) were most employed in child-focused interventions. Most interventions were implemented at one socio-ecological level; child-focused interventions mostly employed community-level strategies (88%). Intervention duration was mostly short; between half a day and a week. Printed or movie-based material was key to deliver child-focused interventions (37%), while professionals most commonly implemented adult-focused interventions (53%). Ten unique, child-focused strategies were all evaluated positively, using a diverse set of scales. Children and adolescents are under-represented in stigma reduction in LMIC. More stigma reduction interventions in LMIC, addressing a wider variety of stigmas, with children as direct and indirect target group, are needed. This systematic review is registered under International Prospective Register of Systematic Reviews PROSPERO, reference number #CRD42018094700.

Development of parallel measures to assess HIV stigma and discrimination among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa

INTRODUCTION

Integrating standardized measures of HIV stigma and discrimination into research studies of emerging HIV prevention approaches could enhance uptake and retention of these approaches, and care and treatment for people living with HIV (PLHIV), by informing stigma mitigation strategies. We sought to develop a succinct set of measures to capture key domains of stigma for use in research on HIV prevention technologies.

METHODS

From 2013 to 2015, we collected baseline data on HIV stigma from three populations (PLHIV (N = 4053), community members (N = 5782) and health workers (N = 1560)) in 21 study communities in South Africa and Zambia participating in the HPTN 071 (PopART) cluster-randomized trial. Forty questions were adapted from a harmonized set of measures developed in a consultative, global process. Informed by theory and factor analysis, we developed seven scales, with values ranging from 0 to 3, based on a 4-point agreement Likert, and calculated means to assess different aspects of stigma. Higher means reflected more stigma. We developed two measures capturing percentages of PLHIV who reported experiencing any stigma in communities or healthcare settings in the past 12 months. We validated our measures by examining reliability using Cronbach's alpha and comparing the distribution of responses across characteristics previously associated with HIV stigma.

RESULTS

Thirty-five questions ultimately contributed to seven scales and two experience measures. All scales demonstrated acceptable to very good internal consistency. Among PLHIV, a scale captured internalized stigma, and experience measures demonstrated that 22.0% of PLHIV experienced stigma in the community and 7.1% in healthcare settings. Three scales for community members assessed fear and judgement, perceived stigma in the community and perceived stigma in healthcare settings. Similarly, health worker scales assessed fear and judgement, perceived stigma in the community and perceived co-worker stigma in healthcare settings. A higher proportion of community members and health workers reported perceived stigma than the proportion of PLHIV who reported experiences of stigma.

CONCLUSIONS

We developed novel, valid measures that allowed for triangulation of HIV stigma across three populations in a large-scale study. Such comparisons will illuminate how stigma influences and is influenced by programmatic changes to HIV service delivery over time.

Workplace-Based Organizational Interventions Promoting Mental Health and Happiness among Healthcare Workers: A Realist Review

Mental illness, deemed globally to account for 32% of years lived with a disability, generates significant impacts on workplaces. In particular, healthcare workers experience high rates of mental ill health such as burnout, stress, and depression due to workplace conditions including excessive workloads, workplace violence and bullying, which also produces negative effects on patients as well as on the happiness and wellbeing of those who remain at work. This review was undertaken to synthesize the evidence on workplace-based interventions at the organizational level promoting mental health and wellbeing among healthcare workers, to identify what has been receiving attention in this area and why, especially considering how such positive effects are produced. A search of three premier health-related databases identified 1290 articles that discussed healthcare workers, workplace interventions, and mental health. Following further examination, 46 articles were ultimately selected as meeting the criteria specifying interventions at the organizational level and combined with similar studies included in a relevant Cochrane review. The 60 chosen articles were then analyzed following a realist framework analyzing context, mechanism, and outcome. Most of the studies included in the realist review were conducted in high-income countries, and the types of organizational-level interventions studied included skills and knowledge development, leadership development, communication and team building, stress management as well as workload and time management. Common themes from the realist review highlight the importance of employee engagement in the intervention development and implementation process. The literature review also supports the recognized need for more research on mental health and happiness in low- and middle-income countries, and for studies evaluating the longer-term effects of workplace mental health promotion.

Advancing health equity through cross-cutting approaches to health-related stigma

Health-related stigma remains a major barrier to improving health and well-being for vulnerable populations around the world. This collection on stigma research and global health emerged largely as a result of a 2017 meeting on the "The Science of Stigma Reduction" sponsored by the US National Institutes of Health (NIH). An overwhelming consensus at the meeting was reached. It was determined that for stigma research to advance further, particularly to achieve effective and scalable stigma reduction interventions, the discipline of stigma research must evolve beyond disease-specific investigations and frameworks and move toward more unified theories of stigma that transcend individual conditions. This introduction reflects on the value of taking this cross-cutting approach from both a historical and current perspective, then briefly summarizes the span of articles. Collectively, the authors apply theory, frameworks, tools, interventions and evaluations to the breadth of stigma across conditions and vulnerabilities. They present a tactical argument for a more ethical, participatory, applied and transdisciplinary line of attack on health-related stigma, alongside promoting the dignity and voice of people living with stigmatized conditions. The collection homepage can be found at http://www.biomedcentral.com/collections/stigma .