The provider perception inventory: psychometrics of a scale designed to measure provider stigma about HIV, substance abuse, and MSM behavior

Measuring intersectional HIV, sexual diversity, and gender non-conformity stigma among healthcare workers in Ghana: scale validation and correlates of stigma

BACKGROUND

Men who have sex with men (MSM) are at heightened risk for HIV acquisition, yet they may delay or avoid HIV testing due to intersectional stigma experienced at the healthcare facility (HCF). Few validated scales exist to measure intersectional stigma, particularly amongst HCF staff. We developed the Healthcare Facility Staff Intersectional Stigma Scale (HCF-ISS) and assessed factors associated with stigma in Ghana.

METHODS

We analyzed baseline data from HCF staff involved in a study testing a multi-level intervention to reduce intersectional stigma experienced by MSM. Data are from eight HCFs in Ghana (HCF Staff n = 200). The HCF-ISS assesses attitudes and beliefs towards same-sex relationships, people living with HIV (PLWH) and gender non-conformity. Exploratory factor analysis assessed HCF-ISS construct validity and Cronbach's alphas assessed the reliability of the scale. Multivariable regression analyses assessed factors associated with intersectional stigma.

RESULTS

Factor analysis suggested an 18-item 3-factor scale including: Comfort with Intersectional Identities in the Workplace (6 items, Cronbach's alpha = 0.71); Beliefs about Gender and Sexuality Norms (7 items, Cronbach's alpha = 0.72); and Beliefs about PLWH (5 items, Cronbach's alpha = 0.68). Having recent clients who engage in same-gender sex was associated with greater comfort with intersectional identities but more stigmatizing beliefs about PLWH. Greater religiosity was associated with stigmatizing beliefs. Infection control training was associated with less stigma towards PLWH and greater comfort with intersectional identities.

CONCLUSIONS

Achieving the goal of ending AIDS by 2030 requires eliminating barriers that undermine access to HIV prevention and treatment for MSM, including HCF intersectional stigma. The HCF-ISS provides a measurement tool to support intersectional stigma-reduction interventions.

HIV-Related Intersectional Stigma and Discrimination Measurement: State of the Science

Background. Across settings, individuals from populations that are multiply stigmatized are at increased risk of HIV and experience worse HIV treatment outcomes. As evidence expands on how intersecting stigmatized identities and conditions influence HIV outcomes, researchers have used diverse quantitative approaches to measure HIV-related intersectional stigma and discrimination. To date, no clear consensus exists regarding how to best quantitatively measure and analyze intersectional stigma and discrimination. Objectives. To review and document existing quantitative measures of HIV-related intersectional stigma and discrimination to inform research, programmatic, and policy efforts. Search Methods. We searched 5 electronic databases for relevant studies. References of included articles were screened for possible inclusion. Additional articles were screened on the basis of consultations with experts in the field. Selection Criteria. We included peer-reviewed studies published between January 1, 2010, and May 12, 2021, that were HIV related and presented 1 or more quantitative measures of stigma and discrimination using an intersectional lens in measure design or analysis. Data Collection and Analysis. Systematic methods were used to screen citations and abstract data via a standardized coding form. Data were analyzed by coding categories stratified according to 2 subgroups: (1) studies incorporating a single intersectional measure and (2) studies that examined intersectional stigma through analytical approaches combining multiple measures. Main Results. Sixteen articles met the inclusion criteria, 7 of which explicitly referenced intersectionality. Ten studies were from the United States. All of the studies included participants living with HIV. Among the 4 studies incorporating a single intersectional stigma measure, 3 explored race and gender stigma and 1 explored gender and HIV stigma. Studies involving analytic approaches (n = 12) mostly examined intersectional stigma via interaction terms in multivariate regression models. Three studies employed structural equation modeling to examine interactive effects or latent constructs of intersectional stigma. Conclusions. Research on the measurement of HIV-related intersectional stigma and discrimination is currently concentrated in high-income settings and generally focuses on the intersection of 2 identities (e.g., race and gender). Efforts are needed to expand appropriate application of intersectionality in the development, adaptation, and use of measures of HIV-related intersectional stigma and discrimination. The use of context-, identity-, or condition-adaptable measures should be considered. Researchers should also carefully consider how to meaningfully engage communities in the process of measurement development. Public Health Implications. The measures and analytic approaches presented could significantly enhance public health efforts in assessing the impact of HIV-related intersectional stigma and discrimination on critical health outcomes. (Am J Public Health. 2022;112(S4):S420-S432. https://doi.org/10.2105/AJPH.2021.306639).

Development and psychometric evaluation of the nurse behavior toward confirmed and suspected HIV/AIDS patients (NB-CSHAP) scale

There is a scarcity of literature discussing nurses’ behaviors toward caring for suspected or confirmed human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients. The development of a scale specific to measure nurses’ behaviors will allow health institutions to assess the disposition of their nurses in terms of HIV care. This study aims to present the rigors of developing and validating a reliable instrument to contextualize these nurses’ behaviors. This study utilized a sequential exploratory mixed method design to develop the NB-CSHAP scale. Thematic analysis was done on the qualitative data from the interviews with persons living with HIV/AIDS (PLHA) from which items were selected to be included in the scale. Exploratory factor analysis was utilized to extract the factors and Cronbach's alpha was used to assess the reliability of the instrument. Four factors were extracted and are categorized as either caring or discriminatory behaviors. These include: (1) service-oriented, (2) openhanded, (3) perceptive, and (4) discriminatory. The scale has an internal consistency of 0.73. The scale shows acceptable psychometric properties, hence can be used to assess the nurses’ behaviors in caring for confirmed or suspected HIV clients. The scale may be used by health institutions to determine the quality of the patient care provided by their nurses to clients with confirmed or suspected HIV.

Tools to measure HIV knowledge, attitudes & practices (KAPs) in healthcare providers: a systematic review

Healthcare providers' knowledge, attitudes and practices (KAPs) related to HIV are important determinants of quality of care provided to HIV/AIDS patients. Most studies have focussed on low- and middle-income countries (LMIC) with far fewer conducted within high-income countries, where the epidemiology of HIV is typically distinct from low- and middle-income countries. As part of a larger study, we wanted to measure HIV-KAPs in healthcare providers in Australia. A systematic search was conducted to identify and evaluate existing tools designed to measure HIV-related KAPs among healthcare providers in higher-income countries. In total, eight instruments were identified. The instruments drew upon adapted forms of existing HIV-related KAPs and stigma theories and were developed based on a range of methodological designs and for different cadre of healthcare workers. The extent to which psychometric properties for each tool were evaluated varied widely. Further research with more robust methodological and psychometric rigour is required for adequate measurement of KAP among health professionals specific to HIV, so associated training needs, patient experiences and health outcomes can potentially be enhanced.

Cross-Cultural Validation of the Health Care Provider HIV/AIDS Stigma Scale (HPASS) in China

The study aimed to validate the Health Care Provider HIV/AIDS Stigma Scale among medical staff in China. The validation was conducted in four steps from March to December 2017: translation and back-translation; content validity test with six experts; test-retest reliability testing with 63 medical staff with 2 weeks interval; and structural validation with 349 medical staff from 52 hospitals with a convenience sample,using exploratory factor analysis,including principal component analysis and varimax rotation. The scale content validity index average was 0.88, while for test-retest reliability, the ICC was 0.87. Three factors of "discrimination", "prejudice" and "stereotype" with 16 items were extracted and explained 59.61% variance. The Cronbach's alpha value for the total scale was of 0.88, and for the three factors, the values were 0.89, 0.86 and 0.74, respectively. The discrimination factor showed identical means between Canadian medical students and Chinese medical staff, while the prejudice and stereotype factors had higher mean scores in the Chinese sample. The three-factor structure of Health Care Provider HIV/AIDS Stigma Scale was confirmed in Chinese medical staff with a simpler solution. This could provide a basis for trans-cultural application and comparison.

Perceptions of HIV-Related Stigma in Portugal Among MSM With HIV Infection and an Undetectable Viral Load

We explored perceptions of HIV-related stigma using a qualitative approach based on the findings of in-depth e-mail asynchronous interviews with 37 self-identified Portuguese men who have sex with men (MSM) with HIV infection and undetectable viral loads. Participants were asked to answer an online interview. Major findings concerned external perceptions of HIV-related stigma, HIV status disclosure, the impact of HIV on everyday life, the presence of double discrimination, and general perceptions of HIV-related stigma. Results revealed (a) stigmatizing and discriminatory behaviors and practices in psychosocial and inter-relational events, but not in accessing and receiving health care; (b) double exposure to stigma associated with being gay and having HIV; and (c) undetectability as an autonomous identity with important connections to social and interpersonal interactions. An important implication was related to multilevel risk perceptions and the psychosocial complexity and challenges of HIV infection. In Portugal, HIV is still a socially disabling disease.

Preliminary investigation of the STBBI Stigma Scale: Description and pilot results

OBJECTIVES

Sexually transmitted and blood-borne infections (STBBIs) are associated with stigmatizing attitudes and beliefs, which can affect the quality of and access to health care, as well as mental health and quality of life. The current study describes the adaptation from an HIV-related stigma scale and pilot testing of a new STBBI Stigma Scale, assessing the stigmatizing attitudes and beliefs of health and social service providers in Canada.

METHODS

144 health and social service providers from across Canada completed the newly adapted scale assessing stigma associated with HIV, hepatitis C, other viral STBBIs and bacterial STBBIs, as well as demographic information, a scale of social desirability and measures of convergent and divergent validity. Participants were recruited through listservs and completed the scale online.

RESULTS

The new scale, consisting of 21 items for each category, demonstrated excellent internal consistency, reliability, and convergent and divergent validity. The factor structure of the scale supports a tripartite model of stigma consisting of stereotyping, prejudice and discrimination. Stereotyping had the highest relative scores on the subscales, and attitudes regarding other viral STBBIs differed significantly from the other STBBI categories.

CONCLUSION

The new scale provides a contextually relevant and applicable psychometrically valid tool to assess STBBI-related stigma among health and social service providers in Canada. The tool can be used to assess attitudes and beliefs, as well as guide self-assessment and possible trainings for providers.

The Development and Piloting of Parallel Scales Measuring External and Internal HIV and Tuberculosis Stigma Among Healthcare Workers in the Free State Province, South Africa

BACKGROUND

The dual burden of tuberculosis and human immunodeficiency virus (HIV) is severely impacting the South African healthcare workforce. However, the use of on-site occupational health services is hampered by stigma among the healthcare workforce. The success of stigma-reduction interventions is difficult to evaluate because of a dearth of appropriate scientific tools to measure stigma in this specific professional setting.

METHODS

The current pilot study aimed to develop and test a range of scales measuring different aspects of stigma-internal and external stigma toward tuberculosis as well as HIV-in a South African healthcare setting. The study employed data of a sample of 200 staff members of a large hospital in Bloemfontein, South Africa.

RESULTS

Confirmatory factor analysis produced 7 scales, displaying internal construct validity: (1) colleagues' external HIV stigma, (2) colleagues' actions against external HIV stigma, (3) respondent's external HIV stigma, (4) respondent's internal HIV stigma, (5) colleagues' external tuberculosis stigma, (6) respondent's external tuberculosis stigma, and (7) respondent's internal tuberculosis stigma. Subsequent analyses (reliability analysis, structural equation modeling) demonstrated that the scales displayed good psychometric properties in terms of reliability and external construct validity.

CONCLUSIONS

The study outcomes support the use of the developed scales as a valid and reliable means to measure levels of tuberculosis- and HIV-related stigma among the healthcare workforce in a resource-limited context. Future studies should build on these findings to fine-tune the instruments and apply them to larger study populations across a range of different resource-limited healthcare settings with high HIV and tuberculosis prevalence.

Mobile technology intervention to improve care coordination between HIV and substance use treatment providers: development, training, and evaluation protocol

Background

People living with HIV (PLWH) with a substance use disorder (SUD) tend to receive inadequate medical care in part because of a siloed healthcare system in which HIV and substance use services are delivered separately. Ideal treatment requires an interdisciplinary, team-based coordinated care approach, but many structural and systemic barriers impede the integration of HIV and SUD services. The current protocol describes the development and preliminary evaluation of a care coordination intervention (CCI), consisting of a tablet-based mobile platform for HIV and SUD treatment providers, an interagency communication protocol, and a training protocol. We hypothesize that HIV and SUD treatment providers will find the CCI to be acceptable, and that after receipt of the CCI, providers will: exhibit higher retention in dual care among patients, report increased frequency and quality of communication, and report increased rates of relational coordination.

Methods/design

A three phase approach is used to refine and evaluate the CCI. Phase 1 consists of in-depth qualitative interviews with 8 key stakeholders as well as clinical audits of participating HIV and SUD treatment agencies. Phase 2 contains functionality testing of the mobile platform with frontline HIV and SUD treatment providers, followed by refinement of the CCI. Phase 3 consists of a pre-, post-test trial with 30 SUD and 30 HIV treatment providers. Data will be collected at the provider, organization, and patient levels. Providers will complete assessments at baseline, immediately post-training, and at 1-, 3-, and 6-months post-training. Organizational data will be collected at baseline, 1-, 3-, and 6-months post training, while patient data will be collected at baseline and 6-months post training.

Discussion

This study will develop and evaluate a CCI consisting of a tablet-based mobile platform for treatment providers, an interagency communication protocol, and a training protocol as a means of improving the integration of care for PLWH who have a SUD. Results have the potential to advance the field by bridging gaps in a fragmented healthcare system, and improving treatment efficiency, work flow, and communication among interdisciplinary providers from different treatment settings.

Trial Registration: NCT02906215

Exploring Service Provider Perceptions of Treatment Barriers Facing Black, Non-Gay-Identified MSMW

Non-gay-identified men who have sex with men and women and who use alcohol and other drugs are a vulnerable population. Little is known about health and medical service provider interaction with these underserved clients. This article presents a thematic analysis of two focus groups undertaken with social and medical service providers regarding the needs of non-gay-identified men who have sex with men and women. Four emergent themes (labeling, constructions of masculinity, HIV/AIDS awareness, and treatment success) illustrate perceived barriers to HIV/AIDS prevention and treatment, as well as treatment success. Implications for policy, practice, and future research are discussed.

Measures of condom and safer sex social norms and stigma towards HIV/AIDS among Beijing MSM

Social norms around condom use and safe sex as well as HIV/AIDS stigma are used to identify persons at higher risk for HIV. These measures have been developed and tested in a variety of settings and populations. While efforts have been undertaken to develop context specific measures of these domains among Chinese MSM, the feasibility of using existing measures is unknown. A survey of MSM, based on respondent-driven sampling, was conducted in Beijing. Existing measures of condom social norms, attitudes towards safer sex and HIV/AIDS stigma were piloted. Internal consistency of all measures was high. As expected higher levels of condom social norms and positive attitudes towards safer sex were associated with condom use. HIV/AIDS stigma and discrimination had a significant relationship with never having an HIV test and lack of discussion of HIV/AIDS with male partners. Correlates of low condom social norms were age, education, employment and resident status. Existing measures of condom social norms, attitudes towards safer sex and HIV/AIDS stigma appear to be appropriate for use among Chinese MSM. Using existing measures as opposed to developing new measures has the potential to expedite investigations into psychosocial correlates of HIV risk behavior.