Stigmatization as a social control mechanism for persons living with HIV and AIDS

Experiences of Migrants Living with HIV from HIV-Endemic Sub-Saharan African Countries: A Systematic Review of Qualitative Research Studies

The aim of this qualitative systematic review was to explore the experiences of migrants living with HIV from HIV endemic sub-Saharan African countries who migrated to high-income countries. In this systematic review of qualitative research studies, we focused on the experiences of migrants living with HIV and the intersections between living with HIV, migration, settlement, culture, race relations, access to health services and HIV care, treatment, and support during migration and settlement in a new host country. We searched 12 electronic databases from database inception for English-language publications. A thematic analysis of qualitative studies [n = 10] was conducted. Complexities exist across the migration and settlement trajectories of migrants living with HIV, which influenced people's level of engagement in the HIV care cascade as well as social determinants of health and social wellbeing.

'Why aren't you on PrEP? You're a gay man': reification of HIV 'risk' influences perception and behaviour of young sexual minority men and medical providers

Public health models and medical interventions have often failed to consider the impact of reductionist HIV 'risk' discourse on how sexual minority men interpret, enact and embody biomedical knowledge in the context of sexual encounters. The aim of this study was to use an anthropological lens to examine sexual minority men's perception of HIV risk and experience within the medical system in order to examine the influence of risk discourse on their health, behaviour and social norms. In-depth interviews (n = 43) were conducted with a racially, ethnically and socioeconomically diverse sample of young sexual minority men and explored HIV-related beliefs and experiences, as well as their interactions with healthcare providers. Findings suggest that the stigmatisation of behaviours associated with HIV appears to be shaped by three key forces: healthcare provider perceptions of sexual minority men as inherently 'risky', community slut-shaming, and perceptions of risk related to anal sex positioning. Stigmatising notions of risk appear to be embodied through sexual health practices and identities vis-à-vis preferred anal sex positions and appear to influence condom use and PrEP initiation.

A scoping review: The utility of participatory research approaches in psychology

Consistent with community psychology's focus on addressing societal problems by accurately and comprehensively capturing individuals' relationships in broader contexts, participatory research approaches aim to incorporate individuals' voices and knowledge into understanding, and responding to challenges and opportunities facing them and their communities. Although investigators in psychology have engaged in participatory research, overall, these approaches have been underutilized. The purpose of this review was to examine areas of research focus that have included participatory research methods and, in turn, highlight the strengths and ways that such methods could be better used by researchers. Nearly 750 articles about research with Indigenous Peoples, children/adolescents, forensic populations, people with HIV/AIDS, older adults, and in the area of industrial-organizational psychology were coded for their use of participatory research principles across all research stages (i.e., research design, participant recruitment and data collection, analysis and interpretation of results, and dissemination). Although we found few examples of studies that were fully committed to participatory approaches to research, and notable challenges with applying and reporting on this type of work, many investigators have developed creative ways to engage respectfully and reciprocally with participants. Based on our findings, recommendations and suggestions for researchers are discussed.

How People Forgive: A Systematic Review of Nurse-Authored Qualitative Research

Purpose: The aim of this systematic review of qualitative forgiveness studies by nurse authors is to contribute to the body of holistic nursing knowledge by discovering answers to the following research questions: (a) where/how does a person get the power to forgive? and (b) what are the people who forgive like? Method: We conducted a systematic search of the English language, peer-reviewed literature for nurse-authored, primary qualitative research that answered our research questions. A total of 188 potential studies were found, and 11 studies met the inclusion criteria. Results: Study participants used interpersonal, intrapersonal, and transpersonal sources of power to forgive, including prayer, meditation, and support from family, friends, and nurses. The findings also revealed the cognitive, emotional, and spiritual traits of forgiving people, including being faith oriented, empathetic, and understanding the meaning of forgiveness as letting go of negative emotions. The findings confirm activities listed under “Forgiveness Facilitation” (2018) in Nursing Interventions Classification (NIC) and suggest additions. Conclusion: This literature review adds to nursing knowledge by synthesizing the findings of the review in a way that provides guidance to nurses to help facilitate forgiveness with patients who want that.

Community Knowledge about Tuberculosis and Perception about Tuberculosis-Associated Stigma in Pakistan

Tuberculosis- (TB) associated stigma is a well-documented phenomenon with various factors, both individual and societal, manifesting its role in shaping health-seeking behavior and contributing to suboptimal TB care in Pakistan. The objective of this study was to assess TB-related knowledge and perceived stigma among community members. This was a cross-sectional survey using a convenience sample of 183 individuals recruited between October and December 2017. A validated stigma measurement tool developed by Van Rie et al. was adapted. Data was analyzed using SPSS version 20.0. A clear majority was aware that TB is curable disease and that it is transmitted by coughing. However, respondents also thought that TB spread through contaminated food, sharing meals, sharing utensils, and by having sexual intercourse with a TB patient. In addition, females, unemployed, and persons having less than six years of education were also more likely to associate stigma with TB. We found an association between the lack of knowledge about TB and perceived stigma. This study highlights the need for improved TB-related education among communities.

Teaching HIV-specific content for pre-licensure nursing and health professions students: a review and synthesis

Persistent Human Immunodeficiency Virus (HIV) prevalence rates remain a challenge, particularly because health care providers (HCP) are not fully prepared to engage in HIV care. This hesitancy to engage creates access to care barriers for people living with HIV (PLWH). We conducted a systematic review to identify educational interventions focused on developing HIV competencies in higher education across health science disciplines. We searched databases for primary studies focused on interventions. Using PRISMA guidelines, we identified 20 articles from 19 distinct studies. While there was an overwhelming body of literature that assessed knowledge, skills, and attitudes in health sciences students on HIV and AIDS, the low number of intervention studies was notable. With the exception of two studies, PLWH were not included in the interventions. This finding stands in sharp contrast to the well-established Greater Involvement of People Living with HIV and/or AIDS (GIPA) and Meaningful Engagement of People Living with HIV and/or AIDS (MEPA) principles. The primary means of the educational intervention was focused on delivering lectures to address HIV and AIDS knowledge for HCP. There was a significant lack of focus on historical, cultural, policy and legal contexts of HIV and AIDS care; theoretical justifications for the interventions were absent. No study focused on the impact of an intervention on the care provided to PLWH by HCP after graduation. There is an urgent need to develop long-term sustainable and scalable interventions that address the consistently identified lack of knowledge and skills, and stigmatizing attitudes of HCP and students.

Social determinants of self-reported health for Canada's indigenous peoples: a public health approach

OBJECTIVE

In Canada, indigenous peoples suffer from a multitude of health disparities. To better understand these disparities, this study aims to examine the social determinants of self-reported health for indigenous peoples in Canada.

STUDY DESIGN

This study uses data from Statistics Canada's Aboriginal Peoples Survey 2012.

METHODS

Multinomial logistic regression models were used to examine how selected social determinants of health are associated with self-reported health among off-reserve First Nations and Métis peoples in Canada.

RESULTS

Our analysis shows that being older, female, and living in urban settings were significantly associated with negative ratings of self-reported health status among the indigenous respondents. Additionally, we found that higher income and levels of education were strongly and significantly associated with positive ratings of self-reported health status. Compared with indigenous peoples with an education level of grade 8 or lower, respondents with higher education were 10 times (5.35-22.48) more likely to report 'excellent' and 'very good' health. Respondents who earned more than $40,000 annually were three times (2.17-4.72) more likely to report 'excellent' and 'very good' health compared with those who earned less than $20,000 annually. When interacted with income, we also found that volunteering in the community is associated with better self-reported health.

CONCLUSIONS

There are known protective determinants (income and education) and risk determinants (location of residence, gender, and age) which are associated with self-reported health status among off-reserve First Nations and Métis peoples. For indigenous-specific determinants, volunteering in the community appears to be associated with self-perceived health status. Thus, addressing these determinants will be necessary to achieve better health outcomes for indigenous peoples in Canada. Next steps include developing indigenous-specific social determinants of health indicators that adequately measure culture, connection, and community.

Medication-Assisted Treatment for Opioid Addiction in the United States: Critique and Commentary

In the United States, buprenorphine products (namely buprenorphine/naloxone combination) and methadone are the primary forms of medication-assisted treatment (MAT) that are authorized for addressing opioid addiction. Although treatment ideologies differentiate MAT programs, much of the provision in the US reflects a model of "high threshold, low tolerance." This model is discussed with a focus on structural and programmatic barriers that shape access to and retention in MAT. The critique continues with a discussion of multifaceted stigma that reinforces spoiled identities and diffuses into treatment settings. The social control mechanisms that are imposed in MAT are strikingly similar to those reflected in criminal justice settings, namely probation, parole and community corrections more generally. Parallels are drawn between the "addict" and the "felon" and how they are monitored, tracked, and controlled. These factors have major implications for recovery.

Alzheimer's disease and the law: positive and negative consequences of structural stigma and labeling in the legal system

OBJECTIVE

To explore the meaning and consequences of labeling on structural stigma in the context of Alzheimer's disease (AD) in the legal system.

METHOD

This qualitative study was made up of three focus groups including social workers and lawyers (n = 26). Participants were asked to report their experience in circumstances in which persons with AD and their family members engage with the legal system. Thematic analysis using the constant comparative method was used.

RESULTS

The discussions in the focus groups raised two overall themes. (1) The significance of the medical diagnostic labeling of AD in the legal system and (2) the consequences of labeling of AD within the legal system. This last theme included four sub-themes: (a) negative consequences of labeling; (b) reasons associated with negative consequences of labeling; (c) positive consequences of labeling; and (d) reasons associated with positive consequences of labeling.

CONCLUSION

Findings of the study provide a first foundation for future research on the meaning and consequences of labeling in legal cases involving persons with AD. They suggest that increasing judges' knowledge about AD and reforming the existing 'status-based' legal capacity legislation might benefit by limiting the legal weight given today to the medical diagnosis.

A focus group qualitative study of HIV stigma in the Canadian healthcare system

Stigma related to HIV in the healthcare system has a pervasive, negative impact on the mental, physical and sexual health of people living with HIV. While well-documented before the advent of antiretroviral treatment, this stigma in Canada has not been as thoroughly examined from a critical perspective since HIV's evolution from an acute to a chronic illness. The current study examines attitudes and beliefs of healthcare providers toward people living with HIV through the use of focus groups. Focus group participants were women living with HIV, men living with HIV, medical and nursing students, and health care providers working with people living with HIV. Data analysis was conducted with a critical lens using an immersion/crystallization approach. Two broad themes emerged from the data: HIV-specific experiences, and components of stigma. Both negative and positive experiences were described. Discrimination, as a behavioural act, was deemed to be the less prevalent and often more covert expression of stigmatization. Stereotyping, including with regard to perceived sexuality, and prejudice were seen as more insidious and perpetuated by both the medical and educational establishments. These findings clearly demonstrate the need for change in terms of reducing the amount of stigma present in these complex, nuanced, and enduring relationships between people living with HIV and the health care system.

A Mixed-Methods Outcome Evaluation of a Mentorship Intervention for Canadian Nurses in HIV Care

We assessed the impact of an HIV care mentorship intervention on knowledge, attitudes, and practices with nurses and people living with HIV (PLWH) in Canada. We implemented the intervention in two urban and two rural sites with 16 mentors (eight experienced HIV nurses and eight PLWH) and 40 mentees (nurses with limited HIV experience). The 6- to 12-month intervention included face-to-face workshops and monthly meetings. Using a mixed-methods approach, participants completed pre- and postintervention questionnaires and engaged in semistructured interviews at intervention initiation, mid-point, and completion. Data from 28 mentees (70%) and 14 mentors (87%) were included in the quantitative analysis. We analyzed questionnaire data using McNemar test, and interview data using content analysis. Results indicated positive changes in knowledge, attitudes, and practices among nurse mentees, with qualitative interviews highlighting mechanisms by which change occurred. Mentorship interventions have the potential to engage and educate nurses in HIV treatment and care.

Development of internalized and personal stigma among patients with and without HIV infection and occupational stigma among health care providers in Southern China

BACKGROUND

HIV/AIDS-related stigma is a major barrier of access to care for those infected with HIV. The aim of this study was to examine, validate, and adapt measuring scales of internalized, personal, and occupational stigma developed in Africa into a Chinese context.

METHODS

A cross-sectional study was conducted from January to September 2015 in Kunming, People's Republic of China. Various scales were constructed on the basis of the previous studies with modifications by experts using exploratory and confirmatory factor analyses (EFA + CFA). Validation of the new scales was done using multiple linear regression models and hypothesis testing of the factorial structure invariance.

RESULTS

The numbers of subjects recruited for the development/validation samples were 696/667 HIV-positive patients, 699/667 non-HIV patients, and 157/155 health care providers. EFA revealed a two-factor solution for internalized and personal stigma scales (guilt/blaming and being refused/refusing service), which were confirmed by CFA with reliability coefficients (r) of 0.869 and 0.853, respectively. The occupational stigma scale was found to have a three-factor structure (blaming, professionalism, and egalitarianism) with a reliability coefficient (r) of 0.839. Higher correlations of factors in the HIV patients (r=0.537) and non-HIV patients (r=0.703) were observed in contrast to low-level correlations (r=0.231, 0.286, and 0.266) among factors from health care providers.

CONCLUSION

The new stigma scales are valid and should be used to monitor HIV/AIDS stigma in different groups of Chinese people in health care settings.

Implementation Process of a Canadian Community-based Nurse Mentorship Intervention in HIV Care

We describe salient individual and organizational factors that influenced engagement of registered nurses in a 12-month clinical mentorship intervention on HIV care in Canada. The intervention included 48 nurses and 8 people living with HIV (PLWH) who were involved in group-based and one-on-one informal mentorship informed by transformative learning theory. We evaluated the process of implementing the mentorship intervention using qualitative content analysis. The inclusion of PLWH as mentors, the opportunities for reciprocal learning, and the long-term commitment of individual nurses and partner organizations in HIV care were major strengths. Challenges included the need for multiple ethical approvals, the lack of organizational support at some clinical sites, and the time commitment required by participants. We recommend that clinical mentorship interventions in HIV care consider organizational support, adhere to the Greater Involvement of People Living with HIV/AIDS principles, and explore questions of professional obligations.

Re-thinking HIV-Related Stigma in Health Care Settings: A Qualitative Study

People living with HIV (PLWH) continue to endure stigma and discrimination in the context of health care. This paper presents the findings of a qualitative study designed to (a) describe stigmatizing and discriminatory practices in health care settings, and (b) explore both symbolic and structural stigma from the perspectives of PLWH. For the purpose of this qualitative study, 21 semi-structured in-depth interviews were conducted in the province of Quebec, Canada. The data were analyzed following the principles of thematic analysis. During analysis, three themes were identified, and relations between these themes were delineated to reflect the experiences of participants. The findings suggest that HIV-related stigma in health care settings is episodic in nature. The findings also suggest that HIV-related stigma is experienced through interactions with health care providers (symbolic stigma) and, finally, that it is applied systematically to manage risk in the context of health care (structural stigma).

A feminist information engagement framework for gynecological cancer patients

Purpose

– The purpose of this paper is to present a three-part framework of information engagement for situated gynecological cancers. These particular cancers intertwine with medicalization of sexuality and gender power dynamics, situating information behaviors and interactions in women’s socio-health perceptions. Using Kavanagh and Broom’s feminist risk framework, the framework establishes functional and temporal parameters for sense-making and information engagement.

Design/methodology/approach

– This paper employs a structured, reiterative literature review with emergent thematic analysis. Nine indices from medicine, information studies, and sociology were searched using combinations of five terms on cervical cancer (CC) and 14 terms on information engagement in the title, abstract, and subject fields. Results were examined on a reiterative basis to identify emergent themes pertaining to knowledge development and information interactions.

Findings

– Environmentally, social stigma and gender roles inhibit information seeking; normalizing CC helps integrate medical, moral, and sexual information. Internally, living with the dichotomy between “having” a body and “being” a body requires high-trust information resources that are presented gradually. Actively, choosing to make or cede medical decision-making requires personally relevant information delivered in the form of concrete facts and explanations.

Research limitations/implications

– The study covers only one country.

Originality/value

– This study’s information framework and suggestions for future research encourage consideration of gender power dynamics, medicalization of sexuality, and autonomy in women’s health information interactions.

Community-academic partnerships in HIV-related research: a systematic literature review of theory and practice

Introduction

Community involvement in HIV research has increased over recent years, enhancing community-academic partnerships. Several terms have been used to describe community participation in research. Clarification is needed to determine whether these terms are synonymous or actually describe different research processes. In addition, it remains unclear if the role that communities play in the actual research process follows the recommendations given in theoretical frameworks of community-academia research.

Objectives

The objective of this study is to review the existing terms and definitions regarding community-academic partnerships and assess how studies are implementing these in relation to conceptual definitions.

Methods

A systematic literature review was conducted in PubMed. Two reviewers independently assessed each article, applying the following inclusion criteria: the article must be published in English before 2013; it must provide an explicit definition and/or defining methodology for a term describing research with a community component; and it has to refer to HIV or AIDS, reproductive health and/or STDs. When disagreements about the relevance of an article emerged, a third reviewer was involved until concordance was reached. Data were extracted by one reviewer and independently verified by a second. Qualitative data were analyzed using MaxQDA for content and thematic analyses while quantitative data were analyzed using descriptive statistics. Community feedback on data analysis and presentation of results was also incorporated.

Results

In total, 246 articles were retrieved, 159 of which fulfilled the inclusion criteria. The number of studies that included community participation in the field of HIV research increased between 1991 and 2012, and the terms used to describe these activities have changed, moving away from action research (AR) to participatory action research (PAR), community-based research (CBR) and community-based participatory research (CBPR), with the latter being the most commonly used term. While definitions of all terms had common characteristics (e.g. participation of community in research process), they varied with regard to the emphasis placed on these characteristics. The nature of community participation in reviewed studies differed considerably from that described in theoretical models.

Conclusions

This study indicates the increase of participatory approaches in HIV research and underlines the need for clarification of terms and a framework providing orientation to community-academia partnerships.

Past experiences, current realities and future possibilities for HIV nursing education and care in Canada

Nurses may have inadequate basic education and opportunities for continuing education in relation to HIV care. As well nurses may perpetuate and impose stigma. We developed, implemented and evaluated an educational intervention to reduce stigma and discrimination among nurses providing HIV care. The intervention used a mentorship model that brought experienced nurses in HIV care and people living with HIV together with nurses who wanted to learn more about HIV nursing care. We examined our findings in relation to past experiences, current realities and future possibilities for HIV nursing education and care in Canada. Our findings demonstrated that many nurses were interested in improving their HIV care, yet few opportunities existed for them to do so. We found that HIV nursing education and expertise were significantly different among participants and across clinical sites. This difference was visible in basic education, services offered for HIV and AIDS care, the collaborative and inter-professional nature of care, and opportunities for continuing education. Mentorship education is an effective strategy to not only address a critical void in knowledge, but also to promote a fundamental shift in attitudes. With the recent call by the World Health Organization to place nurses in key positions to provide HIV care, treatment and prevention, it is imperative to prepare nurses at both the undergraduate and graduate level, as well as those in practice, to fulfill this call.

Patient-provider perceptions on engagement in HIV care in Argentina

Approximately 30% of patients participating in the national antiretroviral therapy (ART) program in Argentina fail to achieve an undetectable viral load, and approximately 25% are not retained in care. This qualitative study was designed to explore and identify factors associated with engagement and retention in public and private health care in Buenos Aires, Argentina. Qualitative data from key informants (n = 12) and focus groups (n = 4 groups) of patients and providers from private and public HIV treatment facilities were recorded and transcribed. Predetermined and arising themes related to adherence, engagement, and retention in care were coded and analyzed using qualitative data analysis software. Reasons identified for patients' lack of adherence or engagement in care differed between patients and providers, and patients attributed limitations to low self-efficacy, fear and concerns about HIV, and lack of provider involvement in treatment. In contrast, providers viewed themselves as decision-makers in patient care and patients as responsible for their own nonadherence due to lack of commitment to their own health or due to medication side effects. Patients reported health care system limitations and HIV concerns contributed to a lack of engagement, and providers identified limited HIV literacy and stigma as additional problems. Both agreed that chronic illness and substance addiction impacted adherence and retention, and agreed on the importance of trust, honesty, and communication in the patient-provider relationship. Results support the incorporation of system-, provider-, and patient-focused components into interventions to facilitate patient engagement, adherence, and retention in public and private settings in Argentina.

Stigma in AIDS nursing care in sub-saharan Africa and the Caribbean

Some nurses who provide AIDS care, in addition to experiencing stigma themselves, also exhibit negative attitudes and perpetrate stigma and discrimination toward persons living with HIV (PLWHAs). We used a participatory research approach to explore the nature, context, and influence of stigma on the nursing care provided to PLWHAs in four low- and middle-income countries: Jamaica, Kenya, South Africa, and Uganda. Eighty-four registered nurses, enrolled nurses, and midwives participated in interviews and 79 participated in 11 focus groups. Nurses were very aware of the stigma and discrimination that AIDS evoked, and made adjustments to their care to decrease the manifestation of AIDS stigma. Despite the assurance that PLWHAs were treated equally, and that universal precautions were used consistently, we found that in reality, nurses sometimes made decisions about nursing care that were based on the appearance of the patient or knowledge of his or her status.

Tóth T, Mocsonaki L, Amirkhanian Y. Effects of Stigmatization on Gay Men Living with HIV/AIDS in a Central-Eastern European Context: A Qualitative Analysis from Hungary

This qualitative study highlights the social dynamics affecting people living with HIV (PLH) in Hungary and in the Central-Eastern European region. The study focused on the special needs and concerns of men living with HIV/AIDS as well as changes in their social relationships and institutional support provision, coping strategies and patterns of social functioning, especially in the context of social stigmatization. Consistent with international qualitative research findings in the field of HIV/AIDS prevention, the present study contributes to a fuller understanding of relationship between sexual behavior, HIV/AIDS related risks and risk perceptions as well as homosexuality-and HIV/AIDS stigma-related social exclusion in a previously under-researched socio-cultural setting. The findings of our study point to several barriers to effective HIV prevention, which should be overcome to improve the present situation by lessening the adverse effects of HIV/AIDS-and homosexuality-related stigma within the gay community, the general population and especially among service providers. One of the main barriers is the lack of public health programs specifically targeting MSM in Hungary, where the predominant mode of HIV transmission remains sex between men.

Are integrated HIV services less stigmatizing than stand-alone models of care? A comparative case study from Swaziland

Introduction

Integrating HIV with primary health services has the potential to reduce HIV-related stigma through delivering care in settings disassociated with HIV. This study investigated the relationship between integrated care and felt stigma. The study design was a comparative case study of four models of HIV care in Swaziland, ranging from fully integrated to fully stand-alone HIV care.

Methods

An exit survey (N=602) measured differences in felt stigma across model of care; the primary outcome “perception of HIV status exposure through clinic attendance” was analyzed using multivariable logistic regression. In-depth interviews (N=22) explored whether and how measured differences in stigma experiences were related to service integration.

Results

There were significant differences in perceived status exposure across models of care. After adjustment for potential confounding between sites, those at a partially integrated site and a partially stand-alone site had greater odds of perceived status exposure than those at the fully stand-alone site (aOR 3.33, 95% CI 1.98–5.60; and aOR 11.84, 95% CI 6.89–20.36, respectively). There was no difference between the fully stand-alone and the fully integrated clinic. Qualitative data suggested that many clients at HIV-only sites felt greater confidentiality knowing that those around them were positive, and support was gained from other HIV care clients. Confidentiality was maintained in various ways, even in stand-alone sites, through separate waiting areas for HIV testing and HIV treatment, and careful clinic and room labelling.

Conclusions

The relationship between model of care and stigma was complex, and the hypothesis that stigma is higher at stand-alone sites did not hold true in this high prevalence setting. Policy-makers should ensure that service integration does not increase stigma, in particular within partially integrated models of care.

An exploration of patient perceptions of adherence to tuberculosis treatment in Tanzania

In this study, we aimed to explore patient perceptions of adherence to tuberculosis (TB) treatment and construct a theoretical model of treatment adherence behavior. We conducted semistructured interviews with 11 adherent patients from Tanzania whom we recruited by purposive sampling. The interview data were analyzed by content analysis. We found that the patient's intention to adhere is the most important determinant of adherence behavior. This intention is preceded by the decision to seek biomedical health care, and based on knowledge and beliefs about TB treatment and the motivation to be cured. The intention to adhere helps patients to cope with perceived barriers to adherence, such as socioeconomic difficulties, and to create an adherence-enabling environment in which the presence of social support plays an important role. Our preliminary adherence behavior model should be validated in larger, nonadherent patient populations and evaluated for its applicability to the development of adherence-promoting strategies.

Methadone as social control: institutionalized stigma and the prospect of recovery

Methadone maintenance treatment (MMT) is an intervention used to treat opioid (heroin) dependence. Several investigators have found that MMT is effective in reducing heroin use and other behaviors; however, a disproportionate number of MMT clients leave treatment prematurely. Moreover, MMT outcome variables are often limited in terms of their measurement. Utilizing an integrated theoretical framework of social control and stigma, we focused on the experiences of methadone maintenance from the perspective of clients. We pooled interview data from four qualitative studies in two jurisdictions and found linkages between social control and institutional stigma that serve to reinforce "addict" identities, expose undeserving customers to the public gaze, and encourage clients to be passive recipients of treatment. We discuss the implications for recovery and suggest recommendations for change.

Health literacy as controversy: an online community's discussion of the U.S. Food and Drug Administration acetaminophen recommendations

Adults in the United States increasingly use the Internet for health information, and online discussions can provide insights into public perceptions of health issues. The purpose of this project was to investigate public perceptions of issues related to health literacy, within the context of a conversation about recommendations to the U.S. Food and Drug Administration, driven by concerns about acetaminophen-related liver injuries due in part to health literacy issues. The discussion took place July 2-8, 2009, on a technology/science blog and included 625 comments. Participants debated the risks and benefits of acetaminophen, and most believed responsibility for taking medication safely falls on consumers. Some were implicitly aware of issues related to health literacy and its relationship to patient outcomes; most felt improved education is all that is needed, whereas others acknowledged that health information is confusing--particularly for the elderly and sick. Recommendations for future research into public perceptions of health literacy are discussed.

Outcomes and processes at a camp for youth with HIV/AIDS

The impact of HIV/AIDS on the lives of youth with this chronic illness suggests the need for additional support as youth develop. Summer camp can serve as a therapeutic intervention for youth with HIV/AIDS. Using a case study employing observations, focus groups, and interviews, we examined outcomes associated with participation in a camp for youth with HIV/AIDS, and program processes that influenced outcomes. Findings showed that camp played a major developmental role for youth. Three outcomes of camp emerged: (a) forming caring connections (awareness of commonalities, lack of isolation); (b) feeling reprieve and recreation (fun activities, anticipation of and reflection on camp, sense of freedom); and (c) increasing knowledge, attitudes, and skills (conflict management, disclosure, skill learning and education, medication adherence). Processes included formal and informal education, staff-camper interactions, long-term relationships, outside-of-camp support, activities, planning for camper needs, accessibility, and freedom from worry. We discuss implications for youth programs.