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Lin C, Nguyen BD, Nguyen TT, Dang HT, Li L, Giang LM. Empowering Women Living with HIV/AIDS in Vietnam: A Hybrid Online-Offline Intervention to Combat Stigma. AIDS Behav 2024:10.1007/s10461-024-04439-3. [PMID: 38992226 DOI: 10.1007/s10461-024-04439-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 07/13/2024]
Abstract
Women living with HIV/AIDS (WLHA) encounter numerous challenges, such as stigma and gender disparities, that hinder their access to care, especially in patriarchal societies like Vietnam. We developed a hybrid intervention with online and offline (in-person) components to empower WLHA in Vietnam. The intervention was pilot tested with 91 WLHA in Hanoi. During baseline and 4-month, study investigators delivered two in-person sessions, one Zoom session, and 15 weeks of Zalo (social media platform) discussions to enhance positive coping strategies, treatment utilization and adherence, and engagement of support from family and peers. The participants continued their Zalo discussions from 4-month to 6-month without investigators' involvement. Intervention outcomes, including active coping and perceived barriers to care, were evaluated at baseline, 4-, and 6-month surveys. Mixed-effects regression models showed that the participants' active coping significantly increased from baseline (50.5 ± 9.4) to 4-month (53.8 ± 6.2; p = 0.0001), although there was a slight decrease at 6-month (52.8 ± 7.2), the change from 4-month to 6-month was not significantly significant (p = 0.3256). There was a significant reduction in participants' perceived barriers to care, from 19.8 ± 5.2 at baseline to 17.4 ± 5.2 at 4-month (p < 0.0001), which remained stable at 17.8 ± 4.3 at 6-month (p < 0.0001 compared to baseline). This intervention presents a promising model to empower WLHA in Vietnam and potentially in similar global contexts. Future interventions could benefit from leveraging natural peer leaders and adopting a more person-centered approach to meet WLHA's varying needs.
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Affiliation(s)
- Chunqing Lin
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, 760 Westwood Plaza, 17-369E, Los Angeles, CA, 90024, USA.
| | - Bich Diep Nguyen
- Center for Training and Research on Substance Use & HIV, Hanoi Medical University, Đống Đa, Vietnam
| | - Thu Trang Nguyen
- Center for Training and Research on Substance Use & HIV, Hanoi Medical University, Đống Đa, Vietnam
| | - Huong Thi Dang
- Center for Training and Research on Substance Use & HIV, Hanoi Medical University, Đống Đa, Vietnam
| | - Li Li
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, 760 Westwood Plaza, 17-369E, Los Angeles, CA, 90024, USA
| | - Le Minh Giang
- Center for Training and Research on Substance Use & HIV, Hanoi Medical University, Đống Đa, Vietnam
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Yang Z, Yang H, Gong B, Zhang L, Fu Y, Hu Y. Exploring Stigma Experience and Coping Strategies Among Women Living with HIV/AIDS in China: A Phenomenological Study. Psychol Res Behav Manag 2024; 17:1487-1498. [PMID: 38601262 PMCID: PMC11006108 DOI: 10.2147/prbm.s456850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/30/2024] [Indexed: 04/12/2024] Open
Abstract
Purpose As of the end of 2022, over 20 million women worldwide, aged 15 and above, are living with HIV. Stigma remains a formidable barrier for women living with HIV/AIDS, hindering their access to healthcare and exacerbating health disparities. Indeed, some women living with HIV/AIDS can successfully confront and overcome stigma. There remains a paucity of qualitative research exploring the stigma coping strategies of women living with HIV/AIDS in China. This study was aimed to gain the deeper understanding of stigma experienced by women living with HIV/AIDS and coping strategies. Patients and Methods We recruited diverse participants using snowball sampling and purposive sampling. Semi-structured personal in-depth interviews were conducted with 30 women living with HIV/AIDS from December 2022 to June 2023. The samples were from four HIV/AIDS designated hospitals. The data were analyzed using the Colaizzi seven-step model. Results The experiences of stigma among women living with HIV/AIDS included family role (wife/mother/grandmother) collapse and disgusted by family, resignation in being shunned by others, helplessness due to social exclusion, grief at being devaluated, and resentment for experiencing injustice. The coping strategies used to deal with stigma included concealing their conditions, avoiding socialization, and attempting to retaliate against society. Conclusion Healthcare professionals are recommended to offer women living with HIV/AIDS effective emotional support and guidance to cope with stigma. The study highlights the stigma they face, providing valuable evidence for policymakers. Recommendations emphasize the importance of developing services addressing both physical and psychological needs of women living with HIV/AIDS.
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Affiliation(s)
- Zhongfang Yang
- Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, People’s Republic of China
- School of Nursing, Fudan University, Shanghai, People’s Republic of China
- Fudan University Centre for Evidence-Based Nursing: A Joanna Briggs Institute Centre of Excellence Department, Fudan University, Shanghai, People’s Republic of China
- NYU Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Hongli Yang
- Department of Nursing, Yunnan Provincial Hospital of Infectious Disease/Yunnan AIDS Care Center/Yunnan Mental Health Center, Kunming, People’s Republic of China
| | - Beibei Gong
- Department of Nursing, The Fourth People’s Hospital of Nanning, Nanning, People’s Republic of China
| | - Lin Zhang
- Department of Nursing, Shanghai Public Health Clinical Center, Shanghai, People’s Republic of China
| | - Yanfen Fu
- School of Nursing, Dali University, Dali, People’s Republic of China
| | - Yan Hu
- Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, People’s Republic of China
- School of Nursing, Fudan University, Shanghai, People’s Republic of China
- Fudan University Centre for Evidence-Based Nursing: A Joanna Briggs Institute Centre of Excellence Department, Fudan University, Shanghai, People’s Republic of China
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Ebrahimi H, Atashzadeh Shoorideh F, Reza Sohrabi M, Ebrahimi M, Hosseini M. An Analysis of Approaches to Reduction of HIV Stigma across the World through educational interventions: A Scoping Review. INVESTIGACION Y EDUCACION EN ENFERMERIA 2024; 42:e06. [PMID: 39083818 PMCID: PMC11290898 DOI: 10.17533/udea.iee.v42n1e06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 12/05/2023] [Indexed: 08/02/2024]
Abstract
Objective To determinate the educational interventions for reducing the stigma caused by HIV worldwide. Methods This scoping review study analyzed all papers published from early 2000 to the end of 2022 by searching all the scientific databases, Scopus, Web of Science, PubMed, Cochrane, Embase and CINHAL. The quality assessment of the papers was done using the ROBIS tool checklist. Results 31papers were admitted to the scoping review process. Stigma reduction intervention was founded on three parts: Society, health and therapeutic services providers, and the patients who had HIV and their families. The interventions included education on the reduction of fear, and shame, observation of protective standards, conducting tests and treatment at the above levels, as well as the support provided by the society, policymakers, religious leaders and families of patients in economic, psychological and cultural terms, together with the establishment of social centres and organization of campaigns. Conclusion The stigma associated with HIV is a significant obstacle before treatment, life expectancy and living quality of patients. Therefore, the stigma associated with this disease can be reduced, and the living quality of patients can be raised using approaches such as education of healthcare service providers and afflicted people, as well as economic, social, cultural, and psychological support.
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Affiliation(s)
- Hamideh Ebrahimi
- 1 Ph.D. Candidate, Student Research Committee, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Foroozan Atashzadeh Shoorideh
- 2 Ph.D. Professor, Department of Psychiatric Nursing and Management, School of Nursing and Midwifery, Shahid Labbafinezhad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mohammad Reza Sohrabi
- 3 Ph.D. Professor, Department of Community Medicine, Social Determinants of Health Research Center, Shahid Labbafinezhad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Masoumeh Ebrahimi
- 4 M.Sc. Clinical Research Development Unit of Pirooz Hospital, Guilan University of Medical Sciences, Rasht, Guilan.
| | - Meimanat Hosseini
- 5 Ph.D. Associate Professor, Department of Community Health Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Davtyan M, Kacanek D, Lee J, Berman C, Chadwick EG, Smith R, Salomon L, Frederick T. Factors associated with internalized HIV-related stigma among biological mothers living with HIV enrolled in a US cohort study. AIDS Care 2024; 36:220-226. [PMID: 37757482 PMCID: PMC10842531 DOI: 10.1080/09540121.2023.2263680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
Understanding factors associated with internalized HIV-related stigma among mothers living with HIV may improve health outcomes. We examined factors (age, race/ethnicity, education, income, employment, marital status, health limitations, and years since HIV diagnosis) associated with internalized HIV-related stigma among biological mothers of children enrolled in the Surveillance Monitoring for ART Toxicities study of the US-based Pediatric HIV/AIDS Cohort Study. Stigma was measured with the Internalized HIV Stigma Scale (IHSS), completed biennially at their child's 11-17-year visits. Linear regression models were fit with generalized estimating equations to evaluate the association between the factors of interest and internalized HIV-related stigma using all completed IHSS surveys. Among 438 eligible mothers, the mean IHSS score was 43.7 (SD = 19.5). Higher IHSS scores were observed for widowed women compared to married women, with an estimated mean difference of 8.91 (95% CI: 2.25, 15.57) after adjusting for age, education, income, and health limitations. Years since HIV diagnosis was associated with internalized HIV-related stigma. For every year of increase since HIV diagnosis, IHSS scores decreased by 0.54 per year, after adjusting for age (95% CI: -0.92, -0.17). Interventions to reduce internalized HIV-related stigma should target mothers who are widowed and those with a more recent HIV diagnosis.
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Affiliation(s)
- Mariam Davtyan
- University of Southern California, Keck School of Medicine, Department of Pediatrics, Los Angeles, California
| | - Deborah Kacanek
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, Massachusetts
| | - Jessica Lee
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, Massachusetts
| | - Claire Berman
- Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, Massachusetts
| | - Ellen G. Chadwick
- Northwestern University, Feinberg School of Medicine, Department of Pediatrics, Chicago, Illinois
| | - Renee Smith
- University of Illinois, College of Medicine, Department of Pediatrics, Chicago, Illinois
| | - Liz Salomon
- Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, Massachusetts
| | - Toinette Frederick
- University of Southern California, Keck School of Medicine, Department of Pediatrics, Los Angeles, California
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Zhang L, Ni Z, Liu Y, Chen H. The effectiveness of e-health on reducing stigma, improving social support and quality of life among people living with HIV: A systematic review and meta-analysis of randomized controlled trials. Int J Nurs Stud 2023; 148:104606. [PMID: 37801937 DOI: 10.1016/j.ijnurstu.2023.104606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 08/21/2023] [Accepted: 09/11/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Many people living with HIV reported poor quality of life, which was primarily due to HIV-related stigma and the lack of social support. Compared with face-to-face interventions, e-health interventions are reported to have potential to help people living with HIV improve their adherence to antiretroviral therapy, promote their management of HIV and depressive symptoms. However, in the literature, the effectiveness of e-health interventions in helping people living with HIV reduce stigma, improve social support and quality of life is unclear. OBJECTIVE To examine the effectiveness of e-health interventions in reducing stigma and improving social support and quality of life among people living with HIV. DESIGN This study is a systematic review and meta-analysis of randomized controlled trials following the Cochrane Handbook guidelines and PRISMA2020. METHODS A comprehensive search was conducted from inception to 1st December 2022 in six databases: PubMed, CINAHL Plus with Full Text, PsycINFO (Ovid), Embase, Web of Science, and CENTRAL (Ovid), and an updated search took place on 11st June 2023. Two authors independently screened the studies and extracted the data. Cochrane's bias risk tool for randomized controlled trials was used to examine the methodological quality of the included studies. The intervention effect was estimated by calculating the standardized mean difference (SMD) and 95 % confidence interval (CI) using Review Manager 5.3. A sensitivity analysis was conducted to test the rigor of the pooled results using one-study-out method. The certainty of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS Nine studies met eligibility criteria and were included in this review. The results of the meta-analysis showed that e-health interventions could statistically significantly reduce stigma (SMD: -0.29, 95 % CI: [-0.48, -0.10], p = 0.002) and improve quality of life (SMD = 0.49, 95 % CI: [0.30, 0.68], P < 0.001), but had no significant effects on social support (SMD = -0.01, 95 % CI: [-0.48, 0.46] P = 0.96). CONCLUSIONS E-health interventions could reduce stigma and improve quality of life among people living with HIV. More studies are needed to further explore if e-health interventions can improve the social support for people living with HIV and investigate how to integrate e-health interventions into the existing health models to help people living with HIV treat and manage HIV/AIDS. REGISTRATION The protocol of this study has been registered in the database PROSPERO (registration ID: CRD42022373299).
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Affiliation(s)
- Liao Zhang
- Department of Nursing, West China Hospital/West China School of Nursing, Sichuan University, PR China
| | - Zhao Ni
- Center for Interdisciplinary Research on AIDS (CIRA), Yale University, New Haven, CT, USA; School of Nursing, Yale University, New Haven, CT, USA
| | - Ying Liu
- Department of Nursing, West China Hospital/West China School of Nursing, Sichuan University, PR China
| | - Hong Chen
- Department of Nursing, West China Hospital/West China School of Nursing, Sichuan University, PR China.
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Ferguson L, Gruskin S, Bolshakova M, Rozelle M, Yagyu S, Kasoka K, Oraro-Lawrence T, Motala A, Stackpool-Moore L, Hempel S. Systematic review and quantitative and qualitative comparative analysis of interventions to address HIV-related stigma and discrimination. AIDS 2023; 37:1919-1939. [PMID: 37352492 PMCID: PMC10552822 DOI: 10.1097/qad.0000000000003628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 06/03/2023] [Accepted: 06/09/2023] [Indexed: 06/25/2023]
Abstract
A strong global commitment exists to eliminate HIV-related stigma and discrimination, and multiple strategies to reduce or eliminate stigma and discrimination have been tried. Using a PICOTS framework and applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria, we undertook a systematic review to determine the success of interventions aiming to address internalized stigma, stigma and discrimination in healthcare, and at the legal or policy level, and to identify their critical success factors. Random effects meta-analyses summarized results wherever possible. We carried out a component analysis to identify and characterize successful interventions. Internalized stigma interventions were diverse: across all studies, we found a reduction of stigma but it was not statistically significant [standardized mean difference (SMD) 0.56; confidence interval (CI) 0.31-1.02; 17 studies). For interventions to address stigma and discrimination in healthcare settings, effect estimates varied considerably but most studies showed positive effects (SMD 0.71; CI 0.60-0.84, 8 studies). Boosted regression analyses found that a combined approach comprising education, counseling, community participation, support person, and access to a HIV specialist often yielded success. Studies of efforts to address stigma and discrimination through law and policy documented, mostly qualitatively, the effect of court cases and directives. Across a range of settings and populations, promising interventions have been identified that, through diverse pathways, have positively impacted the types of stigma and discrimination studied. This evidence base must be built upon and brought to scale to help reach global HIV-related targets and, most importantly, improve the health and quality of life of people with HIV.
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Affiliation(s)
- Laura Ferguson
- Institute on Inequalities in Global Health, University of Southern California
| | - Sofia Gruskin
- Institute on Inequalities in Global Health, University of Southern California
| | - Maria Bolshakova
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Mary Rozelle
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Sachi Yagyu
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | | | | | - Aneesa Motala
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | | | - Susanne Hempel
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
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Bryant JV, Carcioppolo N, Lun D, Potter J. Entertainment-education to reduce internalized stigma, increase intimate partner status disclosure intentions, and increase antiretroviral medical adherence intentions: A randomized controlled trial targeting black women living with HIV in the Southern U.S. Soc Sci Med 2023; 327:115945. [PMID: 37182297 DOI: 10.1016/j.socscimed.2023.115945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/06/2023] [Accepted: 05/01/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Black women in the Southern U.S. account for 67% of all new HIV diagnoses across women of all races and ethnicities. In comparison to women of other racial and ethnic identities, Black women disproportionately experience internalized stigma, lower levels of disclosure self-efficacy, and lower rates of medical adherence. The disclosure processes model hypothesizes that persons living with HIV can be disclosure avoidance oriented or disclosure approach oriented. Disclosure avoidance is facilitated by various forms of stigma and negative outcome expectations. While disclosure approach orientation is facilitated by factors such as positive disclosure attitudes and disclosure self-efficacy. Despite the important role of disclosure in ending the HIV epidemic, extant interventions are limited. Recent research suggests entertainment-education (EE) may be an effective intervention for HIV status disclosure. Entertainment-education is a persuasive strategy that consists of intentionally embedding health and social messages into entertaining content. METHODS The present study evaluated the comparative efficacy of the 90 DAYS film for improving internalized HIV stigma, disclosure beliefs, positive disclosure attitudes, disclosure self-efficacy, HIV disclosure intentions, and medical adherence intentions. A randomized controlled trial was employed consisting of 130 Black women living with HIV in the Southern U.S. Participants were recruited primarily via a Qualtrics panel and randomly assigned to either view the 90 DAYS film or a standard of care brochure. RESULTS Results indicated the EE condition significantly outperformed the brochure condition on the following outcomes: disclosure beliefs (p = .046), positive disclosure attitudes (p = .008), disclosure self-efficacy (p = .007), and intentions to disclose to an intimate partner (p = .038). Statistically significant differences were not observed for internalized stigma or medical adherence intentions. CONCLUSION Findings suggest that EE is an effective strategy for improving psychosocial influences of disclosure and disclosure intentions. Theoretical and practical implications of this work are discussed.
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Affiliation(s)
- Jazmyne V Bryant
- Division of Health Science, Florida A&M University, 334 Palmer Avenue, Tallahassee, FL, 32307, USA.
| | - Nick Carcioppolo
- Dept of Communication Studies, University of Miami, 5100 Brunson Dr, Coral Gables, FL, 33146, USA
| | - Di Lun
- Dept of Health Disparities Research, University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - JoNell Potter
- Dept of Obstetrics and Gynecology, University of Miami, 8932 SW 97th Ave, Miami, FL, 33176, USA
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Walsh JL, John SA, Quinn KG, Hirshfield S, O’Neil A, Petroll AE. Factors associated with quality of life, depressive symptoms, and perceived stress among rural older adults living with HIV in the United States. J Rural Health 2023; 39:488-498. [PMID: 36510755 PMCID: PMC10038895 DOI: 10.1111/jrh.12730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Rural older people living with HIV (PLH) in the United States are a population of growing size and significance. A better understanding of factors associated with quality of life (QOL), depressive symptoms, and stress in this population-especially modifiable factors-could inform future interventions. METHODS Online or on paper, we surveyed 446 PLH aged 50+ residing in rural counties across the United States (Mage = 56, 67% male, 67% White, and 23% Black). Associations between social support, HIV stigma, satisfaction with medical care, discrimination in health care settings, and structural barriers and health-related QOL, depressive symptoms, and perceived stress were assessed using multiple linear regressions. FINDINGS Controlling for demographics, greater social support was associated with better QOL, fewer depressive symptoms, and less stress. Greater HIV stigma was associated with more depressive symptoms and stress. Satisfaction with care was associated with better QOL and less stress. Discrimination in medical settings was associated with lower QOL and more depressive symptoms and stress. Finally, experiencing more structural barriers was associated with lower QOL and more depressive symptoms and stress. CONCLUSIONS In addition to engagement in care and viral suppression, QOL and mental health are also critical considerations for rural older PLH. Increasing social support, reducing or providing skills to cope with HIV stigma, improving quality of care, reducing discrimination and stigma in medical settings, and reducing or mitigating the impact of structural barriers present potential targets for interventions aiming to improve the well-being of older rural PLH.
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Affiliation(s)
- Jennifer L. Walsh
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Steven A. John
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Katherine G. Quinn
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sabina Hirshfield
- STAR Program, Department of Medicine, SUNY Downstate Health Sciences University, New York, New York, USA
| | - Andrew O’Neil
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Andrew E. Petroll
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Tang C, Goldsamt LA, Yu S, Zhao T, Wang H. Psychological pathways to HIV-related posttraumatic stress disorder symptoms among people living with HIV in China: the mediating role of rumination. AIDS Care 2023; 35:165-169. [PMID: 35749306 DOI: 10.1080/09540121.2022.2092713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The occurrence of HIV-related posttraumatic stress disorder (PTSD) compromises the physical and mental health of people living with HIV (PLWH). This study examined the psychological pathways of HIV-related PTSD symptoms considering the influence of rumination in PLWH of China. A cross-sectional survey was conducted in Changsha, China. The data were collected using the PTSD Checklist-Civilian Version, the Ruminative Response Scale, the Multidimensional Scale of Perceived Social Support, and measures of sociodemographic and HIV-related clinic characteristics. A total of 602 PLWH were surveyed. The average score of HIV-related PTSD symptoms was (34.54 ± 13.58). The mediation model showed that perceived social stigma and physical health exhibited direct associations with PTSD symptoms (β = 0.093, -0.145, respectively), while the direct relations of family support, friend support and significant others support to PTSD symptoms were not significant. Rumination mediated the effect of perceived social stigma (β = 0.077), physical health (β = -0.150), family support (β = -0.144) and friend support (β = -0.105) on PTSD symptoms. The study findings underscore the importance of routinely assessing PTSD for PLWH, and developing trauma-focused interventions that alleviate HIV-related PTSD symptoms and reduce rumination while improving social support and physical health and reducing social stigma.
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Affiliation(s)
- Chulei Tang
- School of Nursing, Nanjing Medical University, Nanjing, People's Republic of China
- Xiangya School of Nursing, Central South University, Changsha, People's Republic of China
| | - Lloyd A Goldsamt
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Simin Yu
- Xiangya School of Nursing, Central South University, Changsha, People's Republic of China
| | - Ting Zhao
- Xiangya School of Nursing, Central South University, Changsha, People's Republic of China
| | - Honghong Wang
- Xiangya School of Nursing, Central South University, Changsha, People's Republic of China
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Mukamana D, Gishoma D, Holt L, Kayiranga D, Na JJ, White R, Nyblade L, Knettel BA, Agasaro C, Relf MV. Dehumanizing language, motherhood in the context of HIV, and overcoming HIV stigma - the voices of Rwandan women with HIV: A focus group study. Int J Nurs Stud 2022; 135:104339. [PMID: 36088732 DOI: 10.1016/j.ijnurstu.2022.104339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Stigma is an underlying cause of health inequities, and a major barrier to HIV prevention, care, and treatment. Experiences of HIV stigma have been shown to reduce engagement in care across the HIV care continuum, from testing and diagnosis to long-term retention in care and anti-retroviral therapy adherence. In Rwanda, approximately 130,000 women are living with HIV, representing a prevalence rate (3.7%) which is substantially higher than Rwandan men (2.2%). Both the national Rwanda and City of Kigali HIV and AIDS strategic plans identify stigma as a key concern for reducing the burden of HIV. OBJECTIVES The first objective of this study was to understand the sources of HIV-related stigma among women living with HIV in Rwanda. The second objective was to understand the cultural, linguistic, and contextual context of HIV-related stigma and the intersection of HIV-related stigma to the HIV care continuum (engagement in care, medication/treatment adherence) among women with HIV in Rwanda. DESIGN This study used a cross-sectional, qualitative design. SETTING AND PARTICIPANTS Three-three women from urban and rural settings in Rwanda were recruited from public HIV treatment and care centers to participate in this study. METHOD Focus groups discussions, guided by a structured interview guide, were used to collect qualitative data. Framework analysis was used to analyze the data, which was collected during July 2018. RESULTS The participants in this study highlighted that Rwandan women with HIV experience all forms of stigma - enacted, anticipated, perceived, and internalized - associated with HIV as well as structural stigma. Further, three major themes - dehumanizing language, importance of motherhood in the context of HIV, and overcoming HIV stigma - emerged from the data. CONCLUSION The results of this study are among the few to give voice and perspective to the stigma experiences of Rwandan women with HIV. The women with HIV participating in this study shed light on the pervasive and culturally constructed effects of stigma that continue to exist. Further, the findings from this study highlighted the significant intersection of the role dehumanizing language experienced by Rwandan women with HIV. Additionally, the intersectional identities of being a woman with HIV and a mother and their relationship to societal and cultural norms and expectations must be considered concurrently. Finally, the beneficial effects of support groups was identified as key in helping Rwandan women with HIV to accept self.
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Affiliation(s)
- Donatilla Mukamana
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, KG 11 Ave, 47, Remera, Kigali, Rwanda
| | - Darius Gishoma
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, KG 11 Ave, 47, Remera, Kigali, Rwanda; University Teaching Hospital of Kigali, KN 4 Ave, Kigali, Rwanda
| | - Lauren Holt
- School of Nursing, Duke University, DUMC 3322, 307 Trent Drive, Durham 27710, NC, USA
| | - Dieudonne Kayiranga
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, KG 11 Ave, 47, Remera, Kigali, Rwanda
| | - Jieun Julia Na
- School of Nursing, Duke University, DUMC 3322, 307 Trent Drive, Durham 27710, NC, USA
| | - Rebecca White
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, KG 11 Ave, 47, Remera, Kigali, Rwanda; University of Illinois Chicago, College of Nursing, 845 S. Damen Ave, Chicago 60612, IL, USA
| | - Laura Nyblade
- RTI International, 701 13th Street NW, Suite 750, Washington 20005-3967, DC, USA
| | - Brandon A Knettel
- School of Nursing, Duke University, DUMC 3322, 307 Trent Drive, Durham 27710, NC, USA; Duke Global Health Institute, Duke University, 3110 Trent Drive, 27710, NC, USA
| | - Charity Agasaro
- Duke University, 2080 Duke University Road, Durham 27708, NC, USA
| | - Michael V Relf
- School of Nursing, Duke University, DUMC 3322, 307 Trent Drive, Durham 27710, NC, USA; Duke Global Health Institute, Duke University, 3110 Trent Drive, 27710, NC, USA.
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11
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Pichon LC, Stubbs AW, Teti M. Snap out stigma photovoice project in the U.S. South. BMC Health Serv Res 2022; 22:795. [PMID: 35725410 PMCID: PMC9208191 DOI: 10.1186/s12913-022-08147-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 06/01/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The purpose of SNAP Out Stigma (SOS) was to design and implement a community-based intervention to reduce HIV-related stigma for people living with HIV (PLWH) in the Deep South. This region is a subset of 9 states including Memphis, Tennessee (project site) driving the epidemic in the United States. The purpose of this paper is to explain how PLWH in the U.S. South used Photovoice to communicate stigmatizing lived experiences and contextualize their intersection with multi-level sources of support. METHODS PLWH attended one-on-one and/or group sessions with other PLWH. In Session 1, PLWH received a project overview, met other participants, received a camera and camera training, completed a standardized internalized stigma scale, discussed experiences of internalized stigma, and were instructed to take 3-10 pictures that captured stigma. In Session 2, PLWH discussed the pictures and their meaning. In Session 3, PLWH expanded on what they shared in previous sessions in a one-on-one interview. Thematic analysis captured key patterns of how PLWH experienced stigma. RESULTS Forty-seven PLWH attended Session 1 and were issued a camera. Of those, 35 completed sessions 2 and 3. Participants self-identified as cis man who has sex with men (n = 18), ciswoman (n = 5), transwoman (n = 10), and non-binary (n = 2). Four emergent themes intersecting with internalizations of stigma were identified including: medical, social support, church, and self. CONCLUSIONS The SOS intervention created a safe space for PLWH to share lived experiences of stigmatization. Photovoice facilitated discussion topics ranging from healing and recovery to overcoming factors of social determinants of HIV. We identified trauma-informed growth as an area of future programs for PLWH.
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Affiliation(s)
- Latrice C. Pichon
- grid.56061.340000 0000 9560 654XDivision of Social and Behavioral Sciences, The University of Memphis, School of Public Health, 3825 Desoto Avenue
- 209 Robison Hall, TN 38152 Memphis, USA
| | - Andrea Williams Stubbs
- grid.56061.340000 0000 9560 654XDivision of Social and Behavioral Sciences, The University of Memphis, School of Public Health, 3825 Desoto Avenue
- 209 Robison Hall, TN 38152 Memphis, USA
| | - Michelle Teti
- grid.134936.a0000 0001 2162 3504Department of Public Health, The University of Missouri, 806 Lewis Hall, Columbia, MO 65211 USA
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12
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Reif S, Rao D, Wilson E, Beckwith N, Frey S, Cooper H, Ward D, Belden M. Adaptation and Preliminary Testing of an Intervention to Reduce Stigma among Individuals Living with HIV in the Deep South. SOCIAL WORK IN PUBLIC HEALTH 2022; 37:1-13. [PMID: 34464238 DOI: 10.1080/19371918.2021.1965937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
HIV-related stigma has been implicated as a contributor to the disproportionate impact of HIV in the US Deep South. However, effective interventions aimed at reducing HIV-related stigma are limited in the region. This study adapted and piloted an HIV-related stigma reduction intervention, the UNITY Workshop, for use among people living with HIV in the Deep South following a modified framework of the ADAPT-ITT model and the five principles of Corrigan's Model of Strategic Stigma Change. The adapted intervention, named the YOUNITY Workshop, was conducted in an experiential, group format and focused on enhancing stigma coping skills. Workshop satisfaction was high, and most participants reported acquiring new skills for coping with HIV-related stigma and HIV status disclosure. Participants also reported benefitting from the social support generated from the workshop and desired additional opportunities to connect with others in the future. This pilot study demonstrated the feasibility and positive preliminary outcomes of conducting a group-based HIV stigma reduction workshop in the Deep South. Future rigorous testing of the YOUNITY Workshop is planned to better examine health outcomes associated with participation.
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Affiliation(s)
- Susan Reif
- Center for Health Policy and Inequalities Research, Duke University, Durham, North Carolina, United States
| | - Deepa Rao
- Department of Global Health, University of Washington, Seattle, United States
| | - Elena Wilson
- Center for Health Policy and Inequalities Research, Duke University, Durham, North Carolina, United States
| | - Nicole Beckwith
- Center for Health Policy and Inequalities Research, Duke University, Durham, North Carolina, United States
| | - Sarah Frey
- Department of Global Health, University of Washington, Seattle, United States
| | - Haley Cooper
- Center for Health Policy and Inequalities Research, Duke University, Durham, North Carolina, United States
| | | | - Micha Belden
- Center for Health Policy and Inequalities Research, Duke University, Durham, North Carolina, United States
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13
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Belden M, Reif S, Cooper H, Shilling S, Mouhanna F, Hipp P, Siegler A. The geographic reach of community-based organizations in addressing HIV-related stigma in the Deep South. AIDS Care 2022; 34:60-68. [PMID: 34632864 PMCID: PMC8758532 DOI: 10.1080/09540121.2021.1978379] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 08/25/2021] [Indexed: 01/03/2023]
Abstract
Community-based organizations (CBOs) have been instrumental in addressing the needs of people living with HIV, however, little is known about their efforts to address HIV-related stigma through stigma reduction efforts. This study examined practices of CBOs related to mitigating HIV-related stigma in nine Deep South states. CBOs were surveyed as part of a larger study through the Gilead COMPASS Initiative. The CBO survey asked CBO leadership about stigma in their communities and services available to address this stigma. Survey respondents (n = 207) indicated that HIV-related stigma was perceived as a substantial barrier to both HIV care and CBO services. Although just over two-thirds of survey participants reported that there were group-level programs to address HIV-related stigma, 73% reported that there were not enough interventions to meet the need in their community. Further, 68% reported a lack of individual-level stigma reduction interventions. A majority reported a lack of public media campaigns to address stigma and a lack of training available to assist CBOs to address stigma. In addition, services to address stigma were reportedly less available in rural areas compared to their urban counterparts. Study findings indicate a need to identify, implement, and scale-up effective interventions to reduce HIV stigma in the US Deep South.
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Affiliation(s)
- Micha Belden
- Center for Health Policy and Inequalities Research, Duke University, Durham, NC, USA
| | - Susan Reif
- Center for Health Policy and Inequalities Research, Duke University, Durham, NC, USA
| | - Haley Cooper
- Center for Health Policy and Inequalities Research, Duke University, Durham, NC, USA
| | - Sara Shilling
- Center for Health Policy and Inequalities Research, Duke University, Durham, NC, USA
| | - Farah Mouhanna
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Palmer Hipp
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Aaron Siegler
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
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14
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Ruiz-Robledillo N, Clement-Carbonell V, Ferrer-Cascales R, Portilla-Tamarit I, Alcocer-Bruno C, Gabaldón-Bravo E. Cognitive Functioning and Its Relationship with Self-Stigma in Men with HIV Who Have Sex with Men: The Mediating Role of Health-Related Quality of Life. Psychol Res Behav Manag 2021; 14:2103-2114. [PMID: 34938135 PMCID: PMC8687686 DOI: 10.2147/prbm.s332494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/11/2021] [Indexed: 12/16/2022] Open
Abstract
Introduction The human immunodeficiency virus (HIV) stills remains a serious public health problem. HIV acquisition has several negative health consequences, such as a cognitive deterioration or health-related quality of life (HRQoL) impairment. Although these negative consequences could be directly related to a significant increase in self-stigma in this population, few previous studies have analysed the possible associations between these variables. This is especially the case in specific groups of people living with HIV, such as men who have sex with men who could be at a greater risk of stigmatisation. The main aim of the present study was to evaluate the association between cognitive functioning, HRQoL and self-stigma in a group of men with HIV who have sex with men. Methods The present study was conducted in the Infectious Diseases Unit of the General University Hospital of Alicante (Spain). The final sample was composed of 70 participants who passed the inclusion and exclusion criteria. All were men with HIV who had sex with men and the sample’s mean age was 45 years. Each participant completed questionnaires on HRQoL and HIV self-stigma. Moreover, they completed an online cognitive assessment through the previously validated platform for cognitive evaluation CogniFit, Inc. Results The obtained results showed a significant association between memory functioning impairment, lower levels of HRQoL and higher HIV self-stigma scores. Hence, HRQoL, in the mental summary domain, was shown to be a significant mediator in the relationship between low memory performance and higher HIV self-stigma. Discussion Neurocognitive impairment could decrease HRQoL in men with HIV who have sex with men, and hence, reinforce the idea widespread in society that having HIV holds serious consequences. This fact, together with the reduced cognitive abilities to fight against their own self-stigma could represent plausible explanations of the obtained results. In this sense, intervention strategies, oriented towards reducing cognitive impairment, such as those based on cognitive training, and other psychological interventions to promote HRQoL could be effective approaches to prevent the negative effects of HIV self-stigma in this population.
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Affiliation(s)
- Nicolás Ruiz-Robledillo
- Department of Health Psychology, Faculty of Health Science, University of Alicante, Alicante, Spain
| | | | - Rosario Ferrer-Cascales
- Department of Health Psychology, Faculty of Health Science, University of Alicante, Alicante, Spain
| | - Irene Portilla-Tamarit
- Department of Health Psychology, Faculty of Health Science, University of Alicante, Alicante, Spain
| | - Cristian Alcocer-Bruno
- Department of Health Psychology, Faculty of Health Science, University of Alicante, Alicante, Spain
| | - Eva Gabaldón-Bravo
- Department of Nursing, Faculty of Health Science, University of Alicante, Alicante, Spain
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15
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The Effect of Virtual Self-Care Education on the Perception of Type 1 Diabetes-Related Stigma in Female Adolescents with Diabetes: A Clinical Trial. JOURNAL OF RESEARCH DEVELOPMENT IN NURSING AND MIDWIFERY 2021. [DOI: 10.52547/jgbfnm.18.2.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
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16
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van der Kooij YL, Kupková A, den Daas C, van den Berk GE, Kleene MJT, Jansen HS, Elsenburg LJ, Schenk LG, Verboon P, Brinkman K, Bos AE, Stutterheim SE. Role of Self-Stigma in Pathways from HIV-Related Stigma to Quality of Life Among People Living with HIV. AIDS Patient Care STDS 2021; 35:231-238. [PMID: 34097466 PMCID: PMC8215416 DOI: 10.1089/apc.2020.0236] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
This study examined the relationships between perceived public stigma, experienced stigma, and quality of life in people living with HIV (PLHIV), and whether self-stigma mediates these relationships. Cross-sectional data were analyzed from 1704 PLHIV in care at OLVG hospital in the Netherlands. We measured different types of stigma (perceived public stigma, experienced stigma, and self-stigma), and various quality-of-life outcomes (disclosure concerns, depression, anxiety, sexual problems, sleeping difficulties, self-esteem, general health, and social support). Structural equation modeling was used to test the paths from different types of stigma to quality-of-life outcomes. All direct effects of self-stigma on quality-of-life outcomes were significant. The final mediation model showed that the effects of both perceived public and experienced stigma on quality-of-life outcomes were mediated by self-stigma. These findings highlight the importance of addressing self-stigma in PLHIV, and call for (psychosocial) interventions that reduce the harmful effects of HIV-related stigma.
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Affiliation(s)
| | - Alžběta Kupková
- Department of Work and Social Psychology, Maastricht University, Maastricht, the Netherlands
| | - Chantal den Daas
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Health Psychology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland
| | | | | | | | | | - Leo G. Schenk
- Hello Gorgeous Foundation, Amsterdam, the Netherlands
| | - Peter Verboon
- Faculty of Psychology, Open University, Heerlen, the Netherlands
| | - Kees Brinkman
- Internal Medicine, OLVG Hospital, Amsterdam, the Netherlands
| | - Arjan E.R. Bos
- Faculty of Psychology, Open University, Heerlen, the Netherlands
| | - Sarah E. Stutterheim
- Department of Work and Social Psychology, Maastricht University, Maastricht, the Netherlands
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17
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Relf MV, L Holzemer W, Holt L, Nyblade L, Ellis Caiola C. A Review of the State of the Science of HIV and Stigma: Context, Conceptualization, Measurement, Interventions, Gaps, and Future Priorities. J Assoc Nurses AIDS Care 2021; 32:392-407. [PMID: 33654005 PMCID: PMC9208366 DOI: 10.1097/jnc.0000000000000237] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Michael V Relf
- Michael V. Relf, PhD, RN, AACRN, ACNS-BC, CNE, ANEF, FAAN, is Associate Dean for Global and Community Health Affairs, Duke University School of Nursing, and Associate Research Professor, Duke Global Health Institute, Durham, North Carolina, USA. William L. Holzemer, PhD, RN, FAAN, is Distinguished Professor and Dean Emeritus, Rutgers University School of Nursing, Newark, New Brunswick, & Blackwood, New Jersey, USA. Lauren Holt, MSN, RN, is a PhD Student, Duke University School of Nursing, Durham, North Carolina, USA. Laura Nyblade, PhD, is Fellow and Senior Technical Advisor, Stigma and Discrimination, Research Triangle International, Washington, DC, USA. Courtney Ellis Caiola, PhD, MPH, RN, CNE, is Assistant Professor, East Carolina University, College of Nursing, Greenville, North Carolina, USA
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18
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Algarin AB, Sheehan DM, Varas-Diaz N, Fennie K, Zhou Z, Spencer EC, Cook CL, Cook RL, Ibanez GE. Enacted HIV-Related Stigma's Association with Anxiety & Depression Among People Living with HIV (PLWH) in Florida. AIDS Behav 2021; 25:93-103. [PMID: 32564164 DOI: 10.1007/s10461-020-02948-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Research has shown that HIV-related stigma contributes to people living with HIV having a higher risk of mental health disorders. Our study examines the association between enacted HIV-related stigma and symptoms of anxiety and depression among PLWH. We used baseline data from 932 PLWH collected from the Florida Cohort study between 2014 and 2018. The sample was majority 45 + years of age (63.5%), male (66.0%), and Black (58.1%). The majority had previously experienced enacted HIV-related stigma (53.1%). Additionally, 56.6% and 65.2% showed mild to moderate/severe levels of anxiety and depression, respectively. Those who experienced any levels of enacted HIV-related stigma (vs none) had significantly greater odds of mild and moderate/severe levels of anxiety (vs no/minimal) (AOR[CI] 1.54[1.13, 2.10], p = 0.006; AOR[CI] 3.36[2.14, 5.26], p < 0.001, respectively) and depression (AOR[CI] 1.61[1.19, 2.18], p = 0.002; AOR[CI] 3.66[2.32, 5.77], p < 0.001, respectively). Findings suggest a need to evaluate interventions for PLWH to reduce the deleterious effects of enacted HIV-related stigma on mental health.
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19
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Watt MH, Knettel BA, Knippler ET, Kisigo G, Ngocho JS, Renju J, Rogathi J, Sao SS, Minja L, Osaki H, Mwamba RN, Mmbaga BT. The development of Maisha, a video-assisted counseling intervention to address HIV stigma at entry into antenatal care in Tanzania. EVALUATION AND PROGRAM PLANNING 2020; 83:101859. [PMID: 32795711 PMCID: PMC7686260 DOI: 10.1016/j.evalprogplan.2020.101859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/10/2020] [Accepted: 07/30/2020] [Indexed: 06/11/2023]
Abstract
HIV stigma has a profound impact on clinical outcomes and undermines the quality of life of people living with HIV (PLWH). Among HIV-negative individuals, misinformation and prejudicial attitudes about HIV can fuel stigma and contribute to discrimination against PLWH. Antenatal care (ANC), with its focus on universal HIV testing, provides a unique entry point to address HIV stigma. This study describes the development of a counseling intervention to address HIV stigma among women and their partners attending a first ANC appointment in Tanzania. Formative work to inform the intervention consisted of qualitative interviews with 32 pregnant and postpartum women (both women living with HIV and HIV-negative women) and 20 healthcare workers. Data were analyzed iteratively, using a thematic analysis approach, to identify intervention targets. The resulting intervention, Maisha (Swahili for "Life"), includes three sessions informed by the HIV Stigma Framework and Cognitive-Behavioral Therapy: a video and brief counseling session prior to HIV testing and, for those who test seropositive for HIV, two additional sessions building on the video content. A pilot test of the intervention is in process. Addressing HIV stigma at the first ANC visit can help individuals living with HIV to overcome stigma-related barriers to the initiation and maintenance of HIV care, and can reduce stigmatizing attitudes among those who test negative for HIV.
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Affiliation(s)
- Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, NC, USA; Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA.
| | | | - Elizabeth T Knippler
- Duke Global Health Institute, Duke University, Durham, NC, USA; Gilling School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - Godfrey Kisigo
- Duke Global Health Institute, Duke University, Durham, NC, USA; Kilimanjaro Clinical Research Institute, Moshi, Tanzania.
| | - James S Ngocho
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania.
| | - Jenny Renju
- Kilimanjaro Christian Medical University College, Moshi, Tanzania; London School of Hygiene and Tropical Medicine, London, UK.
| | - Jane Rogathi
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania.
| | - Saumya S Sao
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Linda Minja
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania.
| | - Haika Osaki
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania.
| | - Rimel N Mwamba
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Blandina T Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, USA; Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania.
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20
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Kedia SK, Dillon PJ, Basu A. A Qualitative Exploration of "Mother First" Identity and Antiretroviral Adherence among African American Women Living with HIV in the Mid-South Region of the United States. HEALTH COMMUNICATION 2020; 35:1190-1199. [PMID: 31167571 DOI: 10.1080/10410236.2019.1623641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The majority of African American women living with HIV are of child-bearing age and large numbers of these women express a desire to have children. Extant research suggests that motherhood provides HIV-positive women with a sense of hope and normalcy and, in some cases, is associated with positive HIV-related health behaviors. Guided by the tenets of the culture-centered approach (CCA), this qualitative study sought to understand the relationship between motherhood identity and ART adherence among a sample of 50 African American women living with HIV in the Mid-South region of the United States. Our theoretically-informed thematic analysis of in-depth interviews with all 50 women produced three primary themes: (1) experiencing HIV through the lens of motherhood, (2) the physical and social realities of the "mother first" orientation while living with HIV, and (3) the impact of the "mother first" orientation on ART adherence and self-care. These findings identify how participants' "mother first" identity orientation interacts with their sociocultural environment to enable and constrain their attempts at ART adherence. The findings also provide empirical evidence to support the CCA's theorizing regarding the ways in which the materiality of structures interact with symbolic cultural meanings to (re)produce health inequalities.
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Affiliation(s)
- Satish K Kedia
- Division of Social and Behavioral Sciences, School of Public Health, University of Memphis
| | | | - Ambar Basu
- Department of Communication, University of South Florida
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21
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Higashi RT, Jain MK, Quirk L, Rich NE, Waljee AK, Turner BJ, Lee SC, Singal AG. Patient and provider-level barriers to hepatitis C screening and linkage to care: A mixed-methods evaluation. J Viral Hepat 2020; 27:680-689. [PMID: 32048397 PMCID: PMC7299760 DOI: 10.1111/jvh.13278] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 01/22/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
Abstract
Achieving practice change can be challenging when guidelines shift from a selective risk-based strategy to a broader population health strategy, as occurred for hepatitis C (HCV) screening (2012-2013). We aimed to evaluate patient and provider barriers that contributed to suboptimal HCV screening and linkage-to-care rates after implementation of an intervention to improve HCV screening and linkage-to-care processes in a large, public integrated healthcare system following the guidelines change. As part of a mixed-methods study, we collected data through patient surveys (n = 159), focus groups (n = 9) and structured observation of providers and staff (n = 9). We used these findings to then inform domains for the second phase, which consisted of semi-structured interviews with patients across the screening-treatment continuum (n = 24) and providers and staff at primary care and hepatology clinics (n = 21). We transcribed and thematically analysed interviews using an integrated inductive and deductive framework. We identified lack of clarity about treatment cost, treatment complications and likelihood of cure as ongoing patient-level barriers to screening and linkage to care. Provider-level barriers included scepticism about establishing HCV screening as a quality metric given competing clinical priorities, particularly for patients with multiple comorbidities. However, most felt positively about adding HCV as a quality metric to enhance HCV screening and linkage to care. Provider engagement yielded suggestions for process improvements that resulted in increased stakeholder buy-in and real-time enhancements to the HCV screening process intervention. Systematic data collection at baseline and during practice change implementation may facilitate adoption and adaptation to improve HCV screening guideline implementation. Findings identified several key opportunities and lessons to enhance the impact of practice change interventions to improve HCV screening and treatment delivery.
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Affiliation(s)
- Robin T. Higashi
- Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9066,Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Rd., Dallas TX 75390
| | - Mamta K. Jain
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Rd., Dallas TX 75390,Department of Internal Medicine, UT Southwestern Medical Center, 5939 Harry Hines Blvd., Dallas, TX 75390-9124,Parkland Health and Hospital System, 5201 Harry Hines Blvd., Dallas, TX 75235
| | - Lisa Quirk
- Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9066
| | - Nicole E. Rich
- Department of Internal Medicine, UT Southwestern Medical Center, 5939 Harry Hines Blvd., Dallas, TX 75390-9124,Parkland Health and Hospital System, 5201 Harry Hines Blvd., Dallas, TX 75235
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, 3110 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5368,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI 48105,Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Rd, Ann Arbor, MI 48109,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP) 2800 Plymouth Road, Ann Arbor, MI 48109
| | - Barbara J. Turner
- Department of Family & Community Medicine, UT Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229,ReACH: Center for Research to Advance Community Health, UT Health Science Center at San Antonio, 7411 John Smith Rd., Suite 1050, San Antonio, TX 78229
| | - Simon Craddock Lee
- Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9066,Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Rd., Dallas TX 75390
| | - Amit G. Singal
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Rd., Dallas TX 75390,Department of Internal Medicine, UT Southwestern Medical Center, 5939 Harry Hines Blvd., Dallas, TX 75390-9124,Parkland Health and Hospital System, 5201 Harry Hines Blvd., Dallas, TX 75235
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22
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A Systematic Mixed Studies Review of the Intersections of Social-Ecological Factors and HIV Stigma in People Living With HIV in the U.S. South. J Assoc Nurses AIDS Care 2020; 30:330-343. [PMID: 31021963 DOI: 10.1097/jnc.0000000000000076] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The role of stigma on psychological wellness and treatment outcomes in people living with HIV (PLWH) has been well documented. However, within the context of the southern United States, the intersection between HIV-related stigma and social-ecological factors has been understudied. Thus, a results-based convergent, mixed synthesis design was used to examine the manifestations of HIV-related stigma in PLWH in the U.S. South. A literature search was conducted using PsycINFO, PubMed (includes MEDLINE), and CINAHL. The first level of screening by title and abstract was administered on 1,829 articles. A full-text screening of 169 studies was completed, and a total of 30 relevant articles were extracted. The mixed synthesis highlighted intervention strategies that can reduce HIV-related stigma while promoting positive health-behavior change. The findings of this review underscored the uniqueness of PLWH in the south and demonstrated the crucial role of intersectionality in investigating HIV-related stigma in treating and preventing HIV.
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Stigma reduction interventions in people living with HIV to improve health-related quality of life. Lancet HIV 2019; 7:e129-e140. [PMID: 31776098 DOI: 10.1016/s2352-3018(19)30343-1] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 11/21/2022]
Abstract
As the UNAIDS 90-90-90 targets for people living with HIV are increasingly being reached in many contexts, health-related quality of life, the so-called fourth 90, warrants special attention. HIV-related stigma and discrimination are major barriers for overall health-related quality of life despite impressive clinical and virological improvements in HIV care. There is a scarcity of well designed intervention studies that document stigma reduction in people living with HIV and few studies that specifically assess the effect of stigma on health-related quality of life. Further, few interventions target discrimination from providers outside of HIV-specific care or involve people living with HIV in both the design and implementation. Lastly, evidence on methods to reduce stigma in several underepresented key populations and geographical regions is insufficient and research on intersectional stigma (ie, the convergence of multiple stigmatised identities) needs further attention.
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Abstract
INTRODUCTION African American women encounter disproportionately high rates of HIV-related morbidity and mortality, which is partially mediated through stigma and its effect on HIV treatment adherence. OBJECTIVE To assess the effect of the UNITY peer support workshop on HIV-related stigma among African American women living with HIV, compared with a time and attention control group. METHODS African American women living with HIV were randomized to the UNITY workshop or a breast cancer education control group. Interventions took place in HIV clinics in Chicago, IL and Birmingham, AL. Participants self-reported HIV-related stigma and social support at baseline, after workshop, and at 4 follow-up visits over 12 months. RESULTS Two hundred thirty-nine participants (UNITY n = 124; breast cancer education n = 115) were assessed over 1 year. Both arms experienced decreases in mean stigma scores over time. Our model estimated that allocation to UNITY was not associated with a significant difference in stigma points over time. Post hoc analysis suggested that preceding increases in perceived social support are associated with decreased HIV-related stigma in this population. CONCLUSIONS Although UNITY did not significantly reduce HIV-related stigma in this population, our findings suggest that social support may be key to HIV-related stigma reduction.
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Chandler R, Ross H, Paul S, Shittu A, Lescano C, Hernandez N, Morrison-Beedy D. The HIP LADIES: A Pilot Health Improvement Project for HIV Prevention in Black College Women. J Assoc Nurses AIDS Care 2019; 30:474-487. [PMID: 31241511 DOI: 10.1097/jnc.0000000000000058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A disproportionate number of new HIV infections in the United States occur in Black women. We pilot-tested feasibility and acceptability of a manualized HIV prevention intervention developed with and for Black college women. We used a prospective, randomized 2-group design, with 3 data collection times. Participants included 18- to 24-year-old Black women (N = 65), who were enrolled at 2 southern universities; 46 completed pre- and post-assessments. We found that participants in the intervention arm had positive changes in HIV knowledge (p < .0001) and behavioral intentions (p = .039) outcomes. There were, however, no significant differences between intervention and control groups when considering motivational factors and behavioral skills that promoted HIV prevention: social norms, condom use self-efficacy, and assertive sexual communication. We found preliminary evidence of efficacy for an HIV prevention intervention tailored to Black college women. Researchers should partner with Black college women to develop and implement HIV prevention interventions.
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Dunn Navarra AM, Viorst Gwadz M, Bakken S, Whittemore R, Cleland CM, D'Eramo Melkus G. Adherence Connection for Counseling, Education, and Support: Research Protocol for a Proof-of-Concept Study. JMIR Res Protoc 2019; 8:e12543. [PMID: 30920377 PMCID: PMC6458537 DOI: 10.2196/12543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022] Open
Abstract
Background The highest rates of new HIV infections are observed in African Americans and Hispanics/Latinos (ethnic minority) adolescents and young adults (youth). HIV-infected ethnic minority youth are less likely to initiate and maintain adherence to antiretroviral treatment (ART) and medical care, as compared with their adult counterparts. Objective The objective of this research protocol was to describe our proposed methods for testing a peer-led mobile health cognitive behavioral intervention, delivered via remote videoconferencing and smartphones with HIV-infected ethnic minority youth, Adherence Connection for Counseling, Education, and Support (ACCESS). Our secondary aim was to obtain initial estimates of the biobehavioral impact of ACCESS on HIV virologic outcomes and self-reported ART adherence, beliefs and knowledge about ART treatment, adherence self-efficacy, and health care utilization (retention in care). Methods An exploratory, sequential mixed-methods study design will be used with conceptual determinants of adherence behavior informed by the information-motivation-behavioral skills model. HIV-infected ethnic minority youth aged 16 to 29 years with a detectable HIV serum viral load of more than 200 copies/ml (N=25) will be recruited. Qualitative pretesting will be conducted, including semistructured, in-depth, individual interviews with a convenience sample meeting the study inclusion criteria. Preliminary analysis of qualitative data will be used to inform and tailor the ACCESS intervention. Testing and implementation will include a one-group pre-posttest pilot, delivered by a trained successful peer health coach who lives with HIV and is well-engaged in HIV care and taking ART. A total of 5 peer-led remote videoconferencing sessions will be delivered using study-funded smartphones and targeting adherence information (HIV knowledge), motivation (beliefs and perceptions), and behavioral skills (self-efficacy). Participant satisfaction will be assessed with poststudy focus groups and quantitative survey methodology. Bivariate analyses will be computed to compare pre- and postintervention changes in HIV biomarkers, self-reported ART adherence, beliefs and knowledge about ART, adherence self-efficacy, and retention in care. Results As of December 2018, we are in the data analysis phase of this pilot and anticipate completion with dissemination of final study findings by spring/summer 2019. The major outcomes will include intervention feasibility, acceptability, and preliminary evidence of impact on serum HIV RNA quantitative viral load (primary adherence outcome variable). Self-reported ART adherence and retention in care will be assessed as secondary outcomes. Findings from the qualitative pretesting will contribute to an improved understanding of adherence behavior. Conclusions Should the ACCESS intervention prove feasible and acceptable, this research protocol will contribute to a shift in existent HIV research paradigms by offering a blueprint for technology-enabled peer-led interventions and models. International Registered Report Identifier (IRRID) DERR1-10.2196/12543
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Affiliation(s)
| | - Marya Viorst Gwadz
- Silver School of Social Work, New York University, New York, NY, United States
| | - Suzanne Bakken
- School of Nursing, Columbia University, New York, NY, United States
| | - Robin Whittemore
- School of Nursing, Yale University, New Haven, CT, United States
| | - Charles M Cleland
- Rory Meyers College of Nursing, New York University, New York, NY, United States
| | - Gail D'Eramo Melkus
- Rory Meyers College of Nursing, New York University, New York, NY, United States
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Ma PHX, Chan ZCY, Loke AY. Self-Stigma Reduction Interventions for People Living with HIV/AIDS and Their Families: A Systematic Review. AIDS Behav 2019; 23:707-741. [PMID: 30298241 DOI: 10.1007/s10461-018-2304-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Stigma is a primary concern for people living with human immunodeficiency virus (HIV)/AIDS (PLWHA), and has great impact on their and their family members' health. While previous reviews have largely focused on the public stigma, this systematic review aims to evaluate the impact of HIV/acquired immunodeficiency syndrome (AIDS)-related self-stigma reduction interventions among PLWHA and their families. A literature search using eight databases found 23 studies meeting the inclusion criteria. Five types of intervention approaches were identified: (1) psycho-educational intervention, (2) supportive intervention for treatment adherence (antiretroviral therapy), (3) psychotherapy intervention, (4) narrative intervention, and (5) community participation intervention. Overall, the reviewed articles suggested a general trend of promising effectiveness of these interventions for PLWHA and their family members. Psycho-educational interventions were the main approach. The results highlighted the need for more interventions targeting family members of PLWHA, and mixed-methods intervention studies.
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Affiliation(s)
- Polly H X Ma
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, GH 525, Kowloon, Hong Kong, China
| | - Zenobia C Y Chan
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, GH 525, Kowloon, Hong Kong, China
| | - Alice Yuen Loke
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, GH 525, Kowloon, Hong Kong, China.
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Abstract
The connection between gender and health has intrigued health professionals in the last few decades. Silencing-the-self theory has brought a considerable clarity in this matter. After around three decades of the theory, the literature related to the theory has immensely flourished and has covered different branches of psychology. The aim of the present work is to provide a comprehensive picture of the qualitative and quantitative research findings that have connected self-silencing to health and well-being of women. This article presents a critical review of relevant articles. These articles have used the self-silencing theory as an explanation of women's higher vulnerability to certain diseases as well as their experience with them. Self-silencing has been found to explain the gender gap in psychiatric disorders like depression, eating disorders and so on. It also influences the resilience and therapeutic effects among female patients with chronic conditions such as cancer, AIDS and so on. Moreover, self-silencing has also been found to be associated with women's health issues such as pre-menstrual dysphoric disorder. The present study discusses the existing literature in a narrative manner along with suggesting some relevant research gaps that can be worth exploring in the future.
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Affiliation(s)
- Sucharita Maji
- Department of Humanities and Social Sciences, Indian Institute of Technology Kanpur, Kanpur, India
| | - Shikha Dixit
- Department of Humanities and Social Sciences, Indian Institute of Technology Kanpur, Kanpur, India
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Pelters B. On mountains and prophets: targeting majorities to support minorities by using norm-critics in health education. Int J Qual Stud Health Well-being 2019; 13:1522203. [PMID: 30289027 PMCID: PMC6179063 DOI: 10.1080/17482631.2018.1522203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This debate article advocates for norm-critics instead of empowering coping and pedagogy of tolerance as an educational approach to mitigate stigmatization as well as blame and guilt for health-deviant minorities within the field of health disparities. Norm-critics is a way of making members of the (presumably healthy) normative majority uncover and question their health-related norms and raise awareness for the processes by which members of that majority re/construct images of stereotypic figures (such as “the fatso” or “the couch-potato”) with certain personal character traits which are to be condemned and, in doing so, limit the acting space of those identified as examples of those figures. The approach, its theoretical background, arguments promoting norm-critics, and some suggestions for its practical application are presented. It is concluded that norm-critics render a valuable and much needed addition to the health intervention repertoire.
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Affiliation(s)
- Britta Pelters
- a School of Health and Welfare , Halmstad University , Halmstad , Sweden
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Peltzer K, Babayigit S, Rodriguez VJ, Jean J, Sifunda S, Jones DL. Effect of a multicomponent behavioural PMTCT cluster randomised controlled trial on HIV stigma reduction among perinatal HIV positive women in Mpumalanga province, South Africa. SAHARA J 2018; 15:80-88. [PMID: 30134772 PMCID: PMC6116698 DOI: 10.1080/17290376.2018.1510787] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: We evaluate the impact a multicomponent, behavioural, prevention of mother to child transmission (PMTCT), cluster randomised controlled trial on HIV stigma reduction among perinatal HIV infected women in rural South Africa. Methods: In a cluster randomised controlled trial, twelve community health centres (CHCs) in Mpumalanga Province, South Africa, were randomised; pregnant women living with HIV enrolled received either: A Standard Care (SC) condition plus time-equivalent attention-control on disease prevention (SC; 6 CHCs; n =357), or an Enhanced Intervention (EI) condition of SC PMTCT plus the ‘Protect Your Family’ intervention (EI; 6 CHCs; n =342). HIV-infected pregnant women in the SC attended four antenatal and two postnatal video sessions; those in the EI, four antenatal and two postnatal group PMTCT sessions, including stigma reduction, led by trained lay health workers. Maternal PMTCT, HIV knowledge and HIV related stigma were assessed. The impact of the EI was ascertained on stigma reduction (baseline, 12 months postnatally). A series of logistic regression and latent growth curve models were developed to test the impact of the intervention. Results: In all, 699 women living with HIV were recruited during pregnancy (8–24 weeks), and assessments were completed prenatally at baseline and at 12 months (59.5%) postnatally. Baseline scores of overall HIV related stigma and the four scale factors (personalised stigma, disclosure concerns, negative self-image, and concern public attitudes) decreased at follow-up in the intervention group, while baseline scores of overall stigma and three scale factors (personalised stigma, negative self-image, and concern public attitudes) increased at follow-up in the control group. Using longitudinal analyses, Model 1, which included time-invariant predictors of stigma assessed over the two time periods of baseline and 12 months, increases in stigma from baseline to 12 months were associated with being unemployed, having been diagnosed with HIV before the current pregnancy, and alcohol use. In Model 2, which included time-varying predictors, lower stigma scores were associated with participation in the intervention, greater male partner involvement, and consistent condom use. Conclusion: The enhanced PMTCT intervention, including stigma reduction, administered by trained lay health workers had a significant effect on the reduction of HIV related stigma. Trial registration: clinicaltrials.gov: number NCT02085356
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Affiliation(s)
- Karl Peltzer
- a HIV/AIDS/STIs and TB (HAST) Research Programme, Human Sciences Research Council , Pretoria , South Africa.,b Department of Research & Innovation , University of Limpopo , Sovenga , South Africa
| | - Suat Babayigit
- c Department of Psychiatry & Behavioral Sciences , University of Miami Miller School of Medicine , Miami , Florida , USA
| | - Violeta J Rodriguez
- c Department of Psychiatry & Behavioral Sciences , University of Miami Miller School of Medicine , Miami , Florida , USA.,d Department of Psychology , University of Georgia , Athens , Georgia , USA
| | - Jenny Jean
- e University of Rochester , Rochester , New York , USA
| | - Sibusiso Sifunda
- a HIV/AIDS/STIs and TB (HAST) Research Programme, Human Sciences Research Council , Pretoria , South Africa
| | - Deborah L Jones
- c Department of Psychiatry & Behavioral Sciences , University of Miami Miller School of Medicine , Miami , Florida , USA.,f Department of Psychiatry , University of Zambia School of Medicine , Lusaka , Zambia
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Valverde E, Rodriguez A, White B, Guo Y, Waldrop-Valverde D. Understanding the Association of Internalized HIV Stigma with Retention in HIV Care. ACTA ACUST UNITED AC 2018; 4. [PMID: 31341949 DOI: 10.16966/2380-5536.159] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Internalized HIV stigma plays a detrimental role in terms of linkage to HIV care and adherence to antiretroviral treatment. Yet, little is known regarding the association of internalized HIV stigma with retention in HIV care. We conducted an analysis of interview and medical record abstraction data collected from 188 HIV positive men and women receiving HIV care in Miami, Florida. Demographic characteristics, HIV risk behaviors and care related factors were used to explore the association of internalized HIV stigma with retention in care in a Poisson regression analysis. The relationship of internalized HIV stigma and retention in care was moderated by the patient's level of engagement with an HIV care provider (p=0.004) in that higher levels of provider engagement were significantly associated with higher retention in care rates among patients with moderate levels of internalized HIV stigma. Additionally, retention in care rates were lower for females than for males and for 18-44 year olds than for individuals 44 years and older. Our findings indicate that higher levels of patient-provider engagement may reduce the impact that internalized HIV stigma has on retention in HIV care for some patients. Interventions with HIV care providers or patients to enhance patient-provider engagement may be beneficial.
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Affiliation(s)
- Eduardo Valverde
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Georgia
| | - Allan Rodriguez
- Division of Infectious Diseases, University of Miami Miller School of Medicine, USA
| | - Becky White
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, USA
| | - Ying Guo
- Department of Biostatistics, Rollins School of Public Health, Emory University, Georgia
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Oswald TM, Winder-Patel B, Ruder S, Xing G, Stahmer A, Solomon M. A Pilot Randomized Controlled Trial of the ACCESS Program: A Group Intervention to Improve Social, Adaptive Functioning, Stress Coping, and Self-Determination Outcomes in Young Adults with Autism Spectrum Disorder. J Autism Dev Disord 2018; 48:1742-1760. [PMID: 29234931 PMCID: PMC5889958 DOI: 10.1007/s10803-017-3421-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this pilot randomized controlled trial was to investigate the acceptability and efficacy of the Acquiring Career, Coping, Executive control, Social Skills (ACCESS) Program, a group intervention tailored for young adults with autism spectrum disorder (ASD) to enhance critical skills and beliefs that promote adult functioning, including social and adaptive skills, self-determination skills, and coping self-efficacy. Forty-four adults with ASD (ages 18-38; 13 females) and their caregivers were randomly assigned to treatment or waitlist control. Compared to controls, adults in treatment significantly improved in adaptive and self-determination skills, per caregiver report, and self-reported greater belief in their ability to access social support to cope with stressors. Results provide evidence for the acceptability and efficacy of the ACCESS Program.
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Affiliation(s)
- Tasha M Oswald
- MIND Institute, U.C. Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA.
- Department of Psychiatry and Behavioral Sciences, U.C. Davis Medical Center, 2230 Stockton Blvd., Sacramento, CA, 95817, USA.
- Portia Bell Hume Behavioral Health and Training Center, 5776 Stoneridge Mall Rd, Pleasanton, CA, 94588, USA.
| | - Breanna Winder-Patel
- MIND Institute, U.C. Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA
- Department of Pediatrics, U.C. Davis Medical Center, 2516 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Steven Ruder
- MIND Institute, U.C. Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA
| | - Guibo Xing
- Center for Healthcare Policy and Research, U.C. Davis Medical Center, 2103 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Aubyn Stahmer
- MIND Institute, U.C. Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA
- Department of Psychiatry and Behavioral Sciences, U.C. Davis Medical Center, 2230 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Marjorie Solomon
- MIND Institute, U.C. Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA
- Department of Psychiatry and Behavioral Sciences, U.C. Davis Medical Center, 2230 Stockton Blvd., Sacramento, CA, 95817, USA
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Yuan JM, Zhang JE, Zheng MC, Bu XQ. Stigma and its influencing factors among Chinese patients with stoma. Psychooncology 2018; 27:1565-1571. [DOI: 10.1002/pon.4695] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/22/2018] [Accepted: 02/26/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Jing Min Yuan
- The Second Clinical Medical College, Yangtze University; Jingzhou Hubei Province China
| | - Jun E Zhang
- School of Nursing; Sun Yat-sen University; Guangzhou China
| | - Mei Chun Zheng
- Department of Colorectal Surgery, Cancer Centre; Sun Yat-sen University; Guangzhou China
| | - Xiu Qing Bu
- School of Nursing; Sun Yat-sen University; Guangzhou China
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Kalichman S, Katner H, Banas E, Kalichman M. Population Density and AIDS-Related Stigma in Large-Urban, Small-Urban, and Rural Communities of the Southeastern USA. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2018; 18:517-525. [PMID: 28190136 DOI: 10.1007/s11121-017-0761-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIDS stigmas delay HIV diagnosis, interfere with health care, and contribute to mental health problems among people living with HIV. While there are few studies of the geographical distribution of AIDS stigma, research suggests that AIDS stigmas are differentially experienced in rural and urban areas. We conducted computerized interviews with 696 men and women living with HIV in 113 different zip code areas that were classified as large-urban, small-urban, and rural areas in a southeast US state with high-HIV prevalence. Analyses conducted at the individual level (N = 696) accounting for clustering at the zip code level showed that internalized AIDS-related stigma (e.g., the sense of being inferior to others because of HIV) was experienced with greater magnitude in less densely populated communities. Multilevel models indicated that after adjusting for potential confounding factors, rural communities reported greater internalized AIDS-related stigma compared to large-urban areas and that small-urban areas indicated greater experiences of enacted stigma (e.g., discrimination) than large-urban areas. The associations between anticipated AIDS-related stigma (e.g., expecting discrimination) and population density at the community-level were not significant. Results suggest that people living in rural and small-urban settings experience greater AIDS-related internalized and enacted stigma than their counterparts living in large-urban centers. Research is needed to determine whether low-density population areas contribute to or are sought out by people who experienced greater AIDS-related stigma. Regardless of causal directions, interventions are needed to address AIDS-related stigma, especially among people in sparsely populated areas with limited resources.
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Affiliation(s)
- Seth Kalichman
- Department of Psychology, University of Connecticut, 406 Babbidge Road, Storrs, CT, 06269, USA.
| | | | - Ellen Banas
- Mercer University Medical School, Macon, GA, USA
| | - Moira Kalichman
- Department of Psychology, University of Connecticut, 406 Babbidge Road, Storrs, CT, 06269, USA
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Baugher AR, Beer L, Fagan JL, Mattson CL, Freedman M, Skarbinski J, Shouse RL. Prevalence of Internalized HIV-Related Stigma Among HIV-Infected Adults in Care, United States, 2011-2013. AIDS Behav 2017; 21:2600-2608. [PMID: 28213821 PMCID: PMC5555833 DOI: 10.1007/s10461-017-1712-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
HIV-infected U.S. adults have reported internalized HIV-related stigma; however, the national prevalence of stigma is unknown. We sought to determine HIV-related stigma prevalence among adults in care, describe which socio-demographic groups bear the greatest stigma burden, and assess the association between stigma and sustained HIV viral suppression. The Medical Monitoring Project measures characteristics of U.S. HIV-infected adults receiving care using a national probability sample. We used weighted data collected from June 2011 to May 2014 and assessed self-reported internalized stigma based on agreement with six statements. Overall, 79.1% endorsed ≥1 HIV-related stigma statements (n = 13,841). The average stigma score was 2.4 (out of a possible high score of six). White males had the lowest stigma scores while Hispanic/Latina females and transgender persons who were multiracial or other race had the highest. Although stigma was associated with viral suppression, it was no longer associated after adjusting for age. Stigma was common among HIV-infected adults in care. Results suggest individual and community stigma interventions may be needed, particularly among those who are <50 years old or Hispanic/Latino. Stigma was not independently associated with viral suppression; however, this sample was limited to adults in care. Examining HIV-infected persons not in care may elucidate stigma's association with viral suppression.
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Affiliation(s)
- Amy R Baugher
- Division of HIV/AIDS Prevention, Centers for Disease Control, 1600 Clifton Road NE, MS E-46, Atlanta, GA, 30329, USA.
| | - Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control, 1600 Clifton Road NE, MS E-46, Atlanta, GA, 30329, USA
| | - Jennifer L Fagan
- Division of HIV/AIDS Prevention, Centers for Disease Control, 1600 Clifton Road NE, MS E-46, Atlanta, GA, 30329, USA
| | - Christine L Mattson
- Division of HIV/AIDS Prevention, Centers for Disease Control, 1600 Clifton Road NE, MS E-46, Atlanta, GA, 30329, USA
| | - Mark Freedman
- Division of HIV/AIDS Prevention, Centers for Disease Control, 1600 Clifton Road NE, MS E-46, Atlanta, GA, 30329, USA
| | - Jacek Skarbinski
- Division of HIV/AIDS Prevention, Centers for Disease Control, 1600 Clifton Road NE, MS E-46, Atlanta, GA, 30329, USA
| | - R Luke Shouse
- Division of HIV/AIDS Prevention, Centers for Disease Control, 1600 Clifton Road NE, MS E-46, Atlanta, GA, 30329, USA
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Darlington CK, Hutson SP. Understanding HIV-Related Stigma Among Women in the Southern United States: A Literature Review. AIDS Behav 2017; 21:12-26. [PMID: 27492025 DOI: 10.1007/s10461-016-1504-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Societal stigmatization of HIV/AIDS due to assumptions about transmission and associated behaviors plays a substantial role in the psychosocial well-being of people living with this chronic illness, particularly for women in traditionally conservative geographic regions. Known for social conservatism, the Southern United States (US) holds the highest incidence rate of HIV infection in the US. A systematic search of four databases was used to identify 27 relevant scientific articles pertaining to HIV-related stigma among women living with HIV/AIDS in the Southern US. These studies revealed a rudimentary understanding of stigma sources, effects, and stigma-reduction interventions in this population. Due to the cultural specificity of stigma, further differentiation of stigma in discrete sectors of the South as well as a dialogue about the moral implications of stigma is necessary to lay the groundwork for patient-centered interventions to mitigate the destructive effects of stigma experienced by women in this region.
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Affiliation(s)
- Caroline K Darlington
- College of Nursing, University of Tennessee, 1200 Volunteer Blvd., Room 337, Knoxville, TN, 37996, USA.
| | - Sadie P Hutson
- College of Nursing, University of Tennessee, 1200 Volunteer Blvd., Room 337, Knoxville, TN, 37996, USA
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Stigmatisation et impact sur le soin : l’exemple des IST/VIH. SEXOLOGIES 2016. [DOI: 10.1016/j.sexol.2016.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Blackstock OJ, Patel VV, Cunningham CO. Use of Technology for HIV Prevention Among Adolescent and Adult Women in the United States. Curr HIV/AIDS Rep 2016; 12:489-99. [PMID: 26412086 DOI: 10.1007/s11904-015-0287-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although the proportion of new HIV infections in the USA among women has decreased over the last few years, still, approximately 20 % of new infections occur annually among adolescent and adult women. The development of effective evidence-based prevention interventions remains an important approach to further decreasing these numbers. Technology-delivered prevention interventions hold tremendous potential due, in part, to their ability to reach beyond the walls of brick-and-mortar intervention sites to engage individuals where they are. While most technology-delivered interventions have focused on adolescents and men who have sex with men, much fewer have specifically targeted adolescent or adult women despite evidence showing that interventions tailored to specific target populations are most effective. We summarize the recently published literature on technology-delivered HIV prevention interventions for US adolescent and adult women and provide suggestions for next steps in this nascent but emergent area of prevention research.
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Affiliation(s)
- Oni J Blackstock
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E. 210th Street, Bronx, NY, 10467, USA.
| | - Viraj V Patel
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E. 210th Street, Bronx, NY, 10467, USA.
| | - Chinazo O Cunningham
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E. 210th Street, Bronx, NY, 10467, USA.
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Marzán-Rodríguez M, Varas-Díaz N, Neilands T. Qualitative Contributions to a Randomized Controlled Trial Addressing HIV/AIDS-Stigma in Medical Students. QUALITATIVE REPORT (ONLINE) 2015; 20:2012-2024. [PMID: 26855975 PMCID: PMC4739842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Specialized training for healthcare professionals (HCP) in order to reduce HIV/AIDS related stigma must be part of a public health model for HIV/AIDS. Tested interventions to reduce HIV/AIDS related stigma among HCP have been mostly absent from these efforts. A qualitative approach was used to assess stigma reduction within a traditional randomized controlled design in order to better understand how our current stigma intervention worked and was understood by 2nd year medical students. After conducting a quantitative follow up survey one-year post intervention we conducted 20 in-depth qualitative interviews with a subsample of our intervention group participants as part of the overall evaluation process. Once the interviews were finished, we transcribed them and used NVivo (v.8) to organized the qualitative data. In the process of analyzing the qualitative data we identified core intervention areas participants described as useful for their training and development: (1) acquiring more HIV/AIDS-related knowledge, (2) increased skills for management of high stigma situations, and (3) the ability to identify socio-structural factors that foster HIV infection among clients. The gathered information is important in order to have a deep understanding of how attitudinal change happens as part of our intervention strategies.
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Affiliation(s)
| | | | - Torsten Neilands
- University of California - San Francisco, San Francisco, California, USA
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Relf MV, Williams M, Barroso J. Voices of Women Facing HIV-Related Stigma in the Deep South. J Psychosoc Nurs Ment Health Serv 2015; 53:38-47. [PMID: 26505522 DOI: 10.3928/02793695-20151020-01] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 10/05/2015] [Indexed: 11/20/2022]
Abstract
One in 139 women will be diagnosed with HIV in their lifetime. Thirty-four years into the epidemic, stigma remains part of the trajectory of the disease process for all individuals with HIV. Stigma associated with HIV makes it difficult for women to access HIV testing and counseling, disclose HIV status to sexual partners and health care providers, seek and remain actively engaged in medical care, effectively self-manage the disease after diagnosis, and adhere to antiretroviral therapy. The current article reports the qualitative results from a study designed to test the feasibility and acceptability of a technologically delivered stigma intervention for women with HIV in the Southeastern United States. Qualitative analysis revealed women with HIV uniformly experience, anticipate, and/or internalize stigma associated with HIV. Consequently, women with HIV experience isolation and a threat to self-concept as they make decisions about disclosure, work to maintain the secrecy of their HIV status, and contemplate a future.
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Relf MV, Silva SG, Williams MS, Moore E, Arscott J, Caiola C, Barroso J. Feasibility of using an iPod touch device and acceptability of a stigma reduction intervention with HIV-infected women in the Deep South. AIDS Behav 2015; 19:1896-904. [PMID: 25761644 DOI: 10.1007/s10461-015-1031-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
As with many infectious diseases throughout history, stigma is a part of the trajectory of the HIV disease process. HIV-related stigma impedes women from being tested for HIV. Once infected, HIV-related stigma hinders women from disclosing their HIV status to sexual partners and health care providers, engaging in medical care, effectively self-managing the disease after infection, and adhering to anti-retroviral therapy. After three decades of the HIV epidemic, no evidenced-based, culturally relevant, gender-specific interventions exist to help women infected with HIV manage the stigma associated with HIV infection. This manuscript reports the feasibility of using an iPod touch device and acceptability of a stigma reduction intervention with HIV-infected women in the Deep South in a mixed-method, randomized clinical trial. Results from the study demonstrate that it is feasible to utilize an iPod touch device to deliver an HIV-related stigma intervention to women. Further, women report that the HIV-related stigma intervention is acceptable and meaningful.
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Affiliation(s)
- Michael V Relf
- Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC, 27710, USA.
| | - Susan G Silva
- Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC, 27710, USA.
| | - Megan Scull Williams
- Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC, 27710, USA.
| | - Elizabeth Moore
- Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC, 27710, USA.
| | - Joyell Arscott
- Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC, 27710, USA.
| | - Courtney Caiola
- Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC, 27710, USA.
| | - Julie Barroso
- School of Nursing & Health Studies, University of Miami, Coral Gables, FL, 33124, USA.
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Hutson SP. Climbing Back Up the Mountain: Reflections From an Exploration of End-of-Life Needs of Persons Living With HIV/AIDS in Appalachian Tennessee. Am J Hosp Palliat Care 2015; 33:972-976. [PMID: 26290520 DOI: 10.1177/1049909115600857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Little is known about the health access and end-of-life (EOL) concerns of persons living with HIV/AIDS (PLWHA) in Appalachia, where religious and cultural values are largely traditional. A qualitative, descriptive study with 9 participants was undertaken to assess EOL care needs among those from South Central Appalachian PLWHA. The focus of the study was to examine subjective data regarding EOL needs assessment related to advanced care planning. Five men and 4 women self-acknowledged a diagnosis of HIV/AIDS and completed a 2-hour face-to-face interview with the nurse researcher. Data were analyzed using qualitative descriptive content analysis methods, including data coding for emergent themes and metaphors. A common metaphor tied content to both struggle and triumph as well as the beauty and ruggedness of the Appalachian region: "Climbing Back up the Mountain." Rich descriptions of the significance of the metaphor match with stigma as the greatest hurdle to overcome in planning and interacting with others, including health care providers and significant others, about EOL care needs and advanced planning preferences. Further, the metaphor was derived directly from quotes offered by participants. Sources of stigma were often intersecting: the disease itself, associations with "promiscuity," sexual minority status, illicit drug use, and so on. Strong spiritual images were contrasted with a common avoidance and disdain of organized religion. Findings were used in refining plans for a larger study of EOL care needs and concerns on the population of PLWHA in 2 Southern Appalachian states. Comparison with other research and insights for providers is included.
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Affiliation(s)
- Sadie P Hutson
- College of Nursing, University of Tennessee, Knoxville, TN, USA
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