Australian lesbian and bisexual women's health and social experiences of living with hepatitis C

An evolutionary concept analysis: stigma among women living with hepatitis C

BACKGROUND

Stigma is a complex social phenomenon that leads to marginalization and influences the course of illness. In the context of hepatitis C virus (HCV), stigma is a well-documented barrier to accessing care, treatment, and cure. In recent years, HCV rates among women have increased, resulting in an urgent need to address stigma and its harmful effects. The purpose of this concept analysis was to investigate stigma in the context of women living with HCV using Rodgers' evolutionary method.

METHODS

PubMed, CINAHL, Scopus, Medline, PsycINFO, and Nursing and Allied Health were used to identify articles describing HCV stigma among women. Articles from peer-reviewed journals and geographic locations, published between 2002-2023, were included in the analysis. As specified in Rodgers' evolutionary method, articles were analyzed with a focus on the concept's context, surrogate and related terms, antecedents, attributes, examples, and consequences.

RESULTS

Following screening, 33 articles were selected for inclusion in the analysis. Discrimination and marginalization were identified as surrogate and related terms to stigma; and antecedents of stigma were identified as limited knowledge, fear of diagnosis, and disclosure. Prevalent attributes of stigma in the literature were described as feelings of decreased self-worth, negative stereotyping, and fear of transmission. Importantly, HCV stigma among women is unique in comparison to other forms of infectious disease-related stigma, primarily due its impact on women's identity as mothers and caregivers. Stigmatization of women living with HCV resulted in negative consequences to personal relationships and healthcare access due to decreased health-seeking behaviours. Although access to HCV treatment has changed considerably over time, a temporal analysis could not be completed due to the limited number of articles.

CONCLUSIONS

Stigma in the context of women living with HCV has its own unique antecedents, attributes, and consequences. This enhanced understanding of stigma among women living with HCV has the potential to inform improved and more effective approaches to care, which will be required to reach HCV elimination. Furthermore, this analysis identifies stigma layering and stigma in the direct-acting antiviral  treatment era as areas for more in-depth future inquiry.

A scoping review of the minority stress processes experienced by sexual and gender minority individuals in pharmacy settings: Implications for health care avoidance

BACKGROUND

Sexual and gender minority (SGM) people may avoid or delay health care interactions. The minority stress model describes distal (discrimination, violence) and proximal (expectation of rejection, concealment, internalized self-dislike) stress processes as possible contributors to the health disparities and avoidance behaviors observed when encountered in health care settings. Pharmacies are accessible health care settings, yet the extent to which SGM individuals experience minority stress processes while using services at the pharmacies is unknown.

OBJECTIVE

This scoping review aimed to identify distal and proximal minority stress processes experienced by SGM individuals and health care avoidance behaviors related to pharmacies or pharmacists.

METHODS

An electronic search of PubMed, Embase, and PsycINFO databases was conducted to search for relevant literature up to September 2022. The search was supplemented with a review of reference lists and contact with experts in the field. Articles were included in the review if they described SGM individuals' perceived experiences within pharmacies or with pharmacists and reported an outcome that could be mapped to a distal or proximal minority stress process.

RESULTS

Eleven articles met the eligibility criteria and were included in the review. Of these, 6 reported the presence of distal stress processes, such as perceived stigma, negative pharmacy staff attitudes, and a lack of awareness of population needs. For proximal stress processes, 5 articles reported on concealment, 4 reported on expectation of rejection, and 1 reported on internalized transphobia. Developing rapport and increasing competence were identified as ways to help mediate the impact of minority stress processes.

CONCLUSION

Minority stress processes and avoidance behaviors are experienced by SGM individuals that relate to pharmacies and pharmacists. Coordinated efforts between professional stakeholders are required to reduce minority stress processes and ensure pharmacy-based services are accessible to all individuals.

Equity in Health: Consideration of Race and Ethnicity in Precision Medicine

The causes for disparities in implementation of precision medicine are complex, due in part to differences in clinical care and a lack of engagement and recruitment of under-represented populations in studies. New tools and large genetic cohorts can change these circumstances and build access to personalized medicine for disadvantaged populations.

Consideration of gender in diagnosis and management of blood-borne viruses: the case of hepatitis C

Gender-sensitive health education and clinical management are key components of successful care for people living with chronic illness, yet there is little research available on the specific needs of women living with hepatitis C viral (HCV) infection. This paper reports on a qualitative investigation of HCV diagnosis, symptoms, health care and wellbeing among 109 women living with HCV in two major cities in Australia. Women's experiences of HCV reflect several gender-specific needs around diagnosis, reproductive health and psycho-social wellbeing. Personal relationships were central to women's experiences of health and health care and remained dominant in their considerations for the future. Particularly because women are more likely than men to be responsible for family, we highlight the need to consider the social issues of stigma, poverty and drug use when caring for Australian women living with HCV.

At the intersection of marginalised identities: lesbian, gay, bisexual and transgender people's experiences of injecting drug use and hepatitis C seroconversion

Although the levels of injecting drug use among lesbian, gay, bisexual and transgender (LGBT) populations are high, we know little about their experiences of injecting drugs or living with hepatitis C virus (HCV) infection. The loss of traditional family and cultural ties means connection to community is important to the well-being of LGBT populations. Although some kinds of drug use are normalised within many LGBT communities, injecting drug use continues to be stigmatised. This exploratory qualitative study of people with newly acquired HCV used semi-structured interviews to explore participants' understandings and awareness of HCV, seroconversion, testing, diagnosis and treatment. We present a secondary thematic analysis of eight LGBT participants of the experience of injecting drugs, living with HCV and having a marginalised sexual or gender identity. Community was central to the participants' accounts. Drug use facilitated connection to a chosen community by suppressing sexual or gender desires allows them to fit in to the mainstream; enacting LGBT community norms of behaviour; and connection through shared drug use. Participants also described feeling afraid to come out about their drug use to LGBT peers because of the associated stigma of HCV. They described a similar stigma associated with HIV within the people who inject drugs (PWID) community. Thus, the combination of being LGBT/living with HIV (a gay disease) and injecting drugs/living with HCV (a junkie's disease) left them in a kind of no-man's-land. Health professionals working in drug and HCV care services need to develop capacity in providing culturally appropriate health-care for LGBT PWID.

Perceived barriers to hepatitis C therapy for patients receiving opioid agonist treatment

OBJECTIVES

To explore attitudes toward hepatitis C antiviral therapy in a real-world setting, we asked patients in opioid agonist treatment who were offered antiviral therapy about perceived barriers to initiating therapy.

METHODS

We recruited patients in opioid agonist treatment who had previously been offered cost-free hepatitis C antiviral therapy in a clinical trial. We collected demographic and open-ended interview data. The semistructured interview guide included questions about attitudes toward hepatitis C therapy and barriers to initiating treatment. Each interview was audio recorded and transcribed verbatim. We used the qualitative editing method to analyze the interview transcripts.

RESULTS

We enrolled 19 patients who had been approached to initiate hepatitis C therapy in a clinical trial. All participants were low-income men, with one third self-identifying as racial minorities. When asked about possible barriers to treatment, multiple problems emerged, including the fear of treatment side effects, difficulties with health care providers, limited access to medical care and health information, and misperceptions about antiviral therapy.

CONCLUSIONS

Despite intense educational efforts, concerns over antiviral therapy, relations with providers, and access to the health care system remain critical barriers. These factors should be addressed to improve antiviral therapy rates for patients receiving opioid agonist treatment.

Our Health, Our Say: Towards a Feminist Perspective of Lesbian Health Psychology

Although women’s health has been a central concern of feminist psychology, lesbian health has been largely overlooked. Adopting a feminist approach, this article considers the distinctiveness of lesbian health psychology by examining the contexts for lesbian health. Notions of disease and risk have underpinned the endeavour of constituting lesbians’ health as a research discipline. Dominant traditions have established lesbian health psychology along key dimensions of difference from heterosexual women: differences in risk and preventive health behaviours, in healthy behaviours, in experiences of healthcare, in mental health and in experiences of discrimination. In this article, I propose an agenda for a critically informed perspective of lesbian health psychology and for explanations that do not reinscribe pathology.

Stigma in the context of hepatitis C: concept analysis

AIM

This paper is a report of a concept analysis of stigma in the context of hepatitis C.

BACKGROUND

Stigma is a complex and powerful social phenomenon that influences the course of illness and marginalizes populations. Knowledge of hepatitis C stigma is central to assisting people with hepatitis C self-manage their illness and reduce the disease burden.

DATA SOURCES

Thirty studies from 1995 to 2007 located in health and social sciences databases constituted the data for an evolutionary concept analysis and ecological theory guide the review.

FINDINGS

Stigma is a subjective and variable, perceived and/or experienced phenomenon, most frequently but not exclusively viewed as negative, that has interrelated intrapersonal, interpersonal and structural or institutional dimensions. The antecedents of hepatitis C stigma are help-seeking situations most frequently occurring in healthcare settings. Attributes include the association of hepatitis C with illicit drug use, fear of transmission of a contagious and life-threatening infection, acceptable level of risk, and the power to impose restrictions on the part of healthcare practitioners, family and friendship networks and society. Stigma consequences are mainly, but not exclusively, negative.

CONCLUSION

A central and distinctive feature of hepatitis C stigma in the Western world is its association with illicit drug use. Further research is required to understand the complexities associated with the sociocultural, situational and structural features that influence the stigma experience as well as the trajectory of the disease to understand the concept better and inform nursing practice.

Everybody's got it, but…: Situational and strategic participation in normalized HCV discourse among injection drug users in Edmonton, Canada

BACKGROUND

The normalization thesis refers to processes whereby stigmatized individuals, groups, and activities are accommodated into everyday social life. This study explored the utility of normalization for understanding the social accommodation of HCV among street-involved injection drug users (IDUs) in a Canadian city.

METHODS

In-depth semi-structured interviews (1-4 hr) were conducted with 61 drug injectors recruited through a harm reduction program and user networks in Edmonton's inner city. ANALYSES AND RESULTS: An inductive approach characterized common and unique themes across participants, using a combination of phenomenological and thematic analyses and the constant comparative method. Most respondents readily participated in a normalized discourse about HCV, wherein 'everybody's got it', transmission is unavoidable, and that being HCV+--while being less serious than HIV--is a defining characteristic of ID use. However, results indicated that participation in normalized HCV discourse was situational, strategic, and at times, contradictory with respect to (a) coping with HCV diagnosis and progression, (b) negotiating riskier or safer injection practices, and (c) disclosing serostatus to others.

CONCLUSIONS

While normalization is useful for understanding the internalization of a medico-epidemiologic concept ('HCV status') into this user population, systematic description of coping and risk management practices relative to IDUs' acceptance or rejection of normalized expectations of HCV is important for developing tailored harm reduction programs and policies.

A systematic review of provider knowledge of hepatitis C: is it enough for a complex disease?

As studies indicate that patients with hepatitis C face poor provider knowledge and even stigmatization, we conducted a systematic review of provider knowledge about and attitudes toward hepatitis C. We searched Medline for original studies between 1990 and 2005. Articles were abstracted to define target population, recruitment strategies, study design, and key findings. Twenty-six publications performed in nine countries were identified. Whereas studies demonstrated an understanding of the nature of hepatitis C, significant knowledge deficits existed related to natural history, diagnostic approaches, and treatment. The relevance of simple measures, such as vaccinations against hepatitis A and B, was underappreciated. While providers were aware of risk factors for the disease, there were substantial misperceptions, with 5%-20% of providers considering casual contact as a risk for disease acquisition. We conclude that while healthcare providers understand the nature of hepatitis C, important knowledge gaps persist, which may constitute barriers to appropriate therapy.

The depiction of stigmatization in research about hepatitis C

In the past decade, there has been an increasing emphasis by researchers regarding the stigmatization of people who are hepatitis C positive as they seek health care. Because the vast majority of people with hepatitis C have a history of injection drug use, they are frequently assumed by practitioners to be injection drug users (IDUs), blamed for acquiring the disease, and viewed as irresponsible, immoral, and unworthy. Such stigmatization may cause people who have hepatitis C to avoid testing, treatment and care, as well as to not disclose their hepatitis C or injection drug use to practitioners. The purpose of this paper is to critically examine the representation of stigmatization in 21 published research reports from 1995 to 2006, with a specific focus on how these depictions have shaped the current understanding of interventions to address stigmatization of people with hepatitis C by health care practitioners. We will identify two themes in this literature: (1) hepatitis C-related stigmatization in health care settings arises primarily from practitioners' negative views of injection drug use, and (2) practitioners' negative attitudes toward people with hepatitis C are the result of their lack of awareness and/or information about the disease and/or about injection drug use. We will illustrate that similar themes have informed anti-stigma initiatives in other diseases, notably HIV/AIDS and mental illness, which have had little sustained effect in changing practitioners' behaviour toward the stigmatized population. In conclusion, we will call for research that considers factors beyond the individual practitioner as contributing to the stigmatization of people with hepatitis C, such as social, structural and institutional forces that shape practitioners' interactions with people with hepatitis C in health care settings.

Mental and physical symptoms associated with lower social support for patients with hepatitis C

AIM: To systematically examine the impact of the hepatitis C virus (HCV) diagnosis on patients’ level of social support in a large-scale study.

METHODS: Patients evaluated and treated for HCV in a tertiary referral center were enrolled in a cross-sectional study. Demographic data, functional and emotional status as measured by the Hospital Anxiety and Depression Scale (HAD) and the Sickness Impact Profile (SIP), severity of liver disease, mode of acquisition, and physical and psychiatric comorbidities were collected from patients or abstracted from the medical record. All participants completed a semi-structured interview, addressing questions of social support.

RESULTS: A total of 342 patients (mean age 45.2 years; 37% women) were enrolled. Ninety-two (27%) patients described lower levels of support by family and friends. Nearly half of the participants (45%) noted the loss of at least one relationship due to the disease. Fears related to transmitting the disease (25%) were common and often associated with ignorance or even discrimination by others (19%). Nearly one fifth of the patients did not share information about their disease with others to avoid being stigmatized. Lower levels of social support were significantly associated with living alone, being unemployed, being excluded from antiviral therapy, having psychiatric comorbidities, contracting HCV through intravenous drug use, having high levels of anxiety and depression as measured by the HAD and negative mood state as measured by the SIP. Patients reporting lower levels of social support also noted more physical symptoms as measured by the SIP.

CONCLUSION: Patients with hepatitis C often face significant social problems, ranging from social isolation to familial stress. The most common concerns reflect a limited insight of patients and their relatives and friends about the disease, the risk factors for its spread, and about potential consequences. Our data suggest that educational interventions targeting support persons and the stressors identified in our findings may lessen or alleviate the social strains patients with hepatitis C experience.

Mental and physical symptoms associated with lower social support for patients with hepatitis C

AIM: To systematically examine the impact of the hepatitis C virus (HCV) diagnosis on patients’ level of social support in a large-scale study.

METHODS: Patients evaluated and treated for HCV in a tertiary referral center were enrolled in a cross-sectional study. Demographic data, functional and emotional status as measured by the Hospital Anxiety and Depression Scale (HAD) and the Sickness Impact Profile (SIP), severity of liver disease, mode of acquisition, and physical and psychiatric comorbidities were collected from patients or abstracted from the medical record. All participants completed a semi-structured interview, addressing questions of social support.

RESULTS: A total of 342 patients (mean age 45.2 years; 37% women) were enrolled. Ninety-two (27%) patients described lower levels of support by family and friends. Nearly half of the participants (45%) noted the loss of at least one relationship due to the disease. Fears related to transmitting the disease (25%) were common and often associated with ignorance or even discrimination by others (19%). Nearly one fifth of the patients did not share information about their disease with others to avoid being stigmatized. Lower levels of social support were significantly associated with living alone, being unemployed, being excluded from antiviral therapy, having psychiatric comorbidities, contracting HCV through intravenous drug use, having high levels of anxiety and depression as measured by the HAD and negative mood state as measured by the SIP. Patients reporting lower levels of social support also noted more physical symptoms as measured by the SIP.

CONCLUSION: Patients with hepatitis C often face significant social problems, ranging from social isolation to familial stress. The most common concerns reflect a limited insight of patients and their relatives and friends about the disease, the risk factors for its spread, and about potential consequences. Our data suggest that educational interventions targeting support persons and the stressors identified in our findings may lessen or alleviate the social strains patients with hepatitis C experience.