Development of an instrument to measure internalized stigma in those with HIV/AIDS

Psychometric properties of stigma and discrimination measurement tools for persons living with HIV: a systematic review using the COSMIN methodology

BACKGROUND

The development of antiretroviral therapy broadly extends the life expectancy of persons living with HIV (PLHIV). However, stigma and discrimination are still great threat to these individuals and the world's public health care system. Accurate and reproducible measures are prerequisites for robust results. Therefore, it is essential to choose an acceptable measure with satisfactory psychometric properties to assess stigma and discrimination. There has been no systematic review of different stigma and discrimination tools in the field of HIV care. Researchers and clinical practitioners do not have a solid reference for selecting stigma and discrimination measurement tools.

METHODS

We systematically searched English and Chinese databases, including PubMed, EMBASE, CINAHL, Web of Science, PsycINFO, ProQuest Dissertations and Theses, The Cochrane Library, CNKI,, and Wanfang, to obtain literature about stigma and discrimination measurement tools that have been developed and applied in the field of HIV. The search period was from 1st January, 1996 to 22nd November 2021. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline (2018 version) was applied to assess the risk of bias for each involved study and summarize the psychometric properties of each tool. The modified version of the Grading of Recommendations Assessment, Development, and, Evaluation (GRADE) method was used to grade the evidence and develop recommendations.

RESULTS

We included 45 studies and 19 PROMs for HIV/AIDS-related stigma and discrimination among PLHIV. All studies had sufficient methodological quality in content validity, structural validity, internal consistency, and the hypothesis testing of structural validity. Limited evidence was found for cross-cultural validity, stability, and criterion validity. No relevant evidence was found concerning measurement error and responsiveness. The Internalized AIDS-related Stigma Scale (IARSS), Internalized HIV Stigma Scale (IHSS), and Wright's HIV stigma scale (WHSS) are recommended for use.

CONCLUSIONS

This study recommends three PROMs for different stigma and discrimination scenarios, including IARSS for its good quality and convenience, IHSS for its broader range of items, higher sensitivity, and greater precision, and WHSS for its comprehensive and quick screening. Researchers should also consider the relevance and feasibility of the measurements before putting them into practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022308579.

The association of HIV-related stigma and psychosocial factors and HIV treatment outcomes among people living with HIV in the Volta region of Ghana: A mixed-methods study

Stigma and discrimination have been identified as significant barriers to HIV treatment among people living with HIV (PLWH). HIV stigma affects decision to seek HIV testing and early treatment. Evidence shows that HIV stigma undermines antiretroviral therapy (ART) adherence by affecting the psychological process such as adjusting and coping with social support. In Ghana, stigma toward PLWH occurs in many ways including rejection by their communities and family members, ostracism, and refusal to engage in social interactions such as eating, sharing a bed, or shaking hands. Therefore. we examined PLWH's experiences with different forms of HIV-related stigma and the impact on HIV treatment outcome in the Volta region of Ghana. We employed a convergent mixed-method approach consisting of a survey with 181 PLWH, four focus group discussions with 24 survey respondents, and in-depth interviews with six providers. We performed independent samples t-test, ANOVA, and chi-square test to test associations in bivariate analysis and analyzed qualitative data using thematic analysis. In all, 49% of survey respondents reported experiencing high internalized stigma, which was associated with high social support and depression (p<0.001). In qualitative interviews, anticipated stigma was the most salient concern of PLWH, followed by internalized and enacted stigma, which all negatively impacted HIV treatment and care. Stigma was experienced on multiple levels and affected psychosocial and treatment outcomes. Findings suggest urgent need for HIV-stigma reduction intervention among PLWH and their family, providers, and community members.

Factors associated with internalized HIV-related stigma among people living with HIV in Thailand

Internalized HIV-related stigma (IHS) among people living with HIV (PLHIV) has been documented as one of the factors contributing to the ongoing AIDS epidemic. The purpose of this study, which was conducted from September 2021 to January 2022, was to measure prevalence and identify factors associated with IHS among research participants who were living with HIV recruited from a research clinic in Chiang Mai, Northern Thailand. Participants were considered to have IHS if they agreed to at least one of the 8 items of the newly developed Thai Internalized HIV-related Stigma Scale (Thai-IHSS). Of the 104 participants, 65.4% were female. The median age was 51.5 years and the duration of known HIV infection was 19.0 years. Fifty-three percent of the participants had IHS as defined by the study. Reduced probability of having IHS was independently associated with certain levels of education (middle or high school education compared with no or primary school) (AOR = 0.30; 95% CI: 0.12-0.77) and increased mental health-related quality of life (AOR = 0.39; 95% CI: 0.18-0.86). The prevalence of IHS among PLHIV in Chiang Mai was high. These findings highlight the requirement for comprehensive mental health care programs for PLHIV to improve their quality of life.

A Systematic Review of the Impact of HIV-Related Stigma and Serostatus Disclosure on Retention in Care and Antiretroviral Therapy Adherence Among Women with HIV in the United States/Canada

This systematic review explores the roles of HIV stigma and disclosure of HIV serostatus in antiretroviral therapy (ART) adherence and retention in care (RIC) among women with HIV (WHIV) in the United States and Canada. We conducted a systematic search of electronic databases (PubMed, Embase, CINAHL, PsycINFO, and Google scholar) to identify peer-reviewed articles published between January 1996 and December 2022. The search yielded 1120 articles after duplicates were removed. Of these, 27 articles met the inclusion criteria. The majority (89%) of the studies were conducted in the United States. The studies included WHIV from diverse racial/ethnic groups, residing in both urban and rural areas. Most of the studies suggested that internalized stigma, perceived community stigma, and fear of disclosure were important barriers to ART adherence and RIC among WHIV. HIV-related stigma experienced within the health care setting was also reported as a factor impacting health care utilization. A few studies identified mental health distress as a potential mechanism accounting for the association and suggested that social support and resilience may buffer the negative effects of stigma and disclosure on ART adherence and RIC among WHIV. Our review indicates that stigma and concerns about disclosure continue to significantly affect HIV health outcomes for WHIV in high-income countries. It underscores the importance of integrated HIV care services and interventions targeting mental health, resilience building, and improved patient-provider relationships for WHIV to enhance ART adherence and RIC. Longitudinal studies and investigations into additional mechanisms are needed to advance understanding and inform women-centered interventions.

The stigma in patients with breast cancer: A concept analysis

Objective

Stigma is a common problem among patients having breast cancer. However, the concept of stigma is vague and not specifically described or clearly defined in the literature. The lack of description or definition has further limited stigma research among patients having breast cancer. Therefore, this study aimed to clarify and analyze the concept of stigma in patients with breast cancer.

Methods

Walker and Avant's concept analysis method was applied to analyze the connotation of stigma in patients with breast cancer. PubMed, Web of Science, PsycINFO, CNKI, Wanfang, VIP, and SinoMed databases were searched from inception until May 31, 2023.

Results

Five stigma-related attributes of patients having breast cancer were identified: (1) impaired body image and physiological function; (2) negative stereotypes; (3) mixed negative feelings about developing breast cancer; (4) a feeling of avoidance; (5) experienced discrimination. Antecedents included the implementation of breast surgery and postoperative time, negative psychological factors, lack of social support, and cultural beliefs. This stigma among patients having breast cancer had significant negative effects on their quality of individual life and marriage, postoperative rehabilitation, and healthcare-seeking behavior.

Conclusions

The concept analysis results clarified the concept of stigma in patients with breast cancer and provided theoretical guidance for the development of the conceptual model of stigma in these patients. What is more, it offered a theoretical basis for future studies related to the development of stigma assessment tools for breast cancer patients and for devising nursing intervention strategies.

A qualitative inquiry of experiences of HIV-related stigma and its effects among people living with HIV on treatment in rural Kilifi, Kenya

Background

The pervasiveness of HIV-related stigma and discrimination, and its consequences on HIV prevention and treatment, have been well documented. However, little is known about the lived experiences of HIV-related stigma and its effects among the general adult population living with HIV in rural African settings. This study set out to explore this knowledge gap.

Methods

From April to June 2018, we conducted in-depth interviews with a convenience sample of 40 adults living with HIV aged 18-58 years in Kilifi, Kenya. A semi-structured interview guide was used to explore experiences of HIV-related stigma and its impact on these adults. A framework approach was used to analyze the data using NVIVO 11 software.

Results

Participants reported experiences of HIV-related stigma in its various forms (anticipated, perceived, internalised, and enacted), as well as its effects on HIV treatment and social and personal spheres. The internalisation of stigma caused by enacted stigma impacted care-seeking behavior resulting in worse overall health. Anxiety and depression characterized by suicidal ideation were the results of internalised stigma. Anticipated stigma prompted HIV medication concealment, care-seeking in remote healthcare facilities, and care avoidance. Fewer social interactions and marital conflicts resulted from perceived stigma. Overall, HIV-related stigma resulted in partial and non-disclosure of HIV seropositivity and medication non-adherence. At a personal level, mental health issues and diminished sexual or marital prospects (for the unmarried) were reported.

Conclusion

Despite high awareness of HIV and AIDS among the general population in Kenya, adults living with HIV in rural Kilifi still experience different forms of HIV-related stigma (including self-stigma) that result in a raft of social, personal, and HIV-treatment-related consequences. Our findings underscore the urgent need to reevaluate and adopt more effective strategies for implementing HIV-related anti-stigma programs at the community level. Addressing individual-level stigma will require the design of targeted interventions. To improve the lives of adults living with HIV in Kilifi, the effects of HIV-related stigma, particularly on HIV treatment, must be addressed.

The Thai Internalized HIV-related Stigma Scale

Introduction

Internalized stigma among people living with HIV has been linked to a range of negative consequences. The current study describes the development and validation of a contextually appropriate internalized HIV-related Stigma Scale for people living with HIV in Thailand.

Methods

The study was carried out in two stages from 2018 to 2019: developing items based on the findings of focus group discussions and pilot testing the original list of items and validating the instrument. In the cross-sectional survey stage, a sample of 400 people living with HIV was used to validate the test items in accordance with their psychometric characteristics.

Results

The study’s outcome was the 22-item Thai Internalized HIV-related Stigma Scale (Thai-IHSS). The exploratory factor analysis showed that the Thai-IHSS consisted of four components: negative thoughts toward self (5 items), anticipated negative thoughts (7 items), effects of negative thought toward self (6 items), and effects of negative thoughts toward family and access to healthcare services (4 items).

Discussion

The Thai-IHSS had acceptable concurrent, convergent, and congruent validity according to the findings. Additionally, the 8-item Thai-IHSS brief, which included two items for each component, was detailed. The Thai-IHSS is valid and reliable for use in Thailand and other countries with comparable sociocultural environments.

Psychosocial and Health-Related Behavioral Outcomes of a Work Readiness HIV Peer Worker Training Program

Targeted work readiness training is an important approach to help people living with HIV (PLHIV) to overcome their unique barriers to work, while addressing social determinants of health needs. This study assesses the psychosocial impacts of a work readiness training and internship program among HIV peer workers in New York City. From 2014 through 2018, 137 PLHIV completed the training program, and 55 individuals completed both the training and the six-month peer internship. Depression, HIV internalized stigma, self-esteem, HIV medication adherence, patient self-advocacy, and safer sex communication apprehension were used as outcome measures. Paired t-tests were performed to determine if significant score changes occurred at the individual level before and after each training. Our results show that participating in the peer worker training program significantly decreased depression and internalized HIV stigma, and significantly increased self-esteem, medication adherence, and patient self-advocacy. The study underscores that peer worker training programs are important tools to improve not only the work readiness of PLHIV, but also psychosocial and health outcomes. Implications for HIV service providers and stakeholders are discussed.

HIV-Specific Reported Outcome Measures: Systematic Review of Psychometric Properties

BACKGROUND

The management of people living with HIV and AIDS is multidimensional and complex. Using patient-reported outcome measures (PROMs) has been increasingly recognized to be the key factor for providing patient-centered health care to meet the lifelong needs of people living with HIV and AIDS from diagnosis to death. However, there is currently no consensus on a PROM recommended for health care providers and researchers to assess health outcomes in people living with HIV and AIDS.

OBJECTIVE

The purpose of this systematic review was to summarize and categorize the available validated HIV-specific PROMs in adults living with HIV and AIDS and to assess these PROMs using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology.

METHODS

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of 3 recommended databases (PubMed, Embase, and PsychINFO) was conducted on January 15, 2021. Studies were included if they assessed any psychometric property of HIV-specific PROMs in adults living with HIV and AIDS and met the eligibility criteria. The PROMs were assessed for 9 psychometric properties, evaluated in each included study following the COSMIN methodology by assessing the following: the methodological quality assessed using the COSMIN risk of bias checklist; overall rating of results; level of evidence assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluation approach; and level of recommendation.

RESULTS

A total of 88 PROMs classified into 8 categories, assessing the psychometric properties of PROMs for adults living with HIV and AIDS, were identified in 152 studies including 79,213 people living with HIV and AIDS. The psychometric properties of most included PROMs were rated with insufficient evidence. The PROMs that received class A recommendation were the Poz Quality of Life, HIV Symptom Index or Symptoms Distress Module of the Adult AIDS Clinical Trial Group, and People Living with HIV Resilience Scale. In addition, because of a lack of evidence, recommendations regarding use could not be made for most of the remaining assessed PROMs (received class B recommendation).

CONCLUSIONS

This systematic review recommends 3 PROMs to assess health outcomes in adults living with HIV and AIDS. However, all these PROMs have some shortcomings. In addition, most of the included PROMs do not have sufficient evidence for assessing their psychometric properties and require a more comprehensive validation of the psychometric properties in the future to provide more scientific evidence. Thus, our findings may provide a reference for the selection of high-quality HIV-specific PROMs by health care providers and researchers for clinical practice and research.

Predictors of Stigma and Health-Related Quality of Life Among People Living with HIV in Northern Thailand

HIV-related stigma and discrimination have been a significant barrier to accessing health care, hence contributing to poor health outcomes. This study aimed to investigate factors associated with HIV-related stigma and discrimination and health-related quality of life (HRQoL) among people living with HIV in rural Thailand setting. A cross-sectional convenience sample of 161 HIV-positive Thai patients was recruited from a single rural district hospital using a self-administered questionnaire entailing sociodemographic information, the 12-item stigma scale, the Medical Outcomes Study HIV Health Survey (MOS-HIV), and the EuroQoL 5-Dimension 5-Level (EQ-5D-5L). Linear regression and the multi-variable analyses were used to investigate factors associated with stigma and HRQoL, whereas the correlations between stigma and quality of life variables were tested by Pearson correlations. Being married and duration of antiretroviral therapy were negatively correlated with HIV stigma, while increased age was inversely associated with HRQoL. Being employed and having sufficient money for living contributed positively to predict HRQoL. HIV stigma was negatively associated with mental health summary (MHS) and visual analog scale (VAS) score, whereas duration diagnosed with HIV and the use of two nucleoside reverse transcriptase inhibitors in combination with protease inhibitor regimen were negative factors associated with VAS and health utility, respectively. The findings confirm complex and inseparable associations of factors relating to HIV-related stigma and HRQoL. The development of effective interventions tailored at individual level is warranted to address this gap.

Association between Internalized Stigma and Depression among People Living with HIV in Thailand

Internalized stigma and depression are among the most common mental health problems in people living with HIV (PLHIV). This study aimed to examine the association between depression and overall internalized stigma, as well as different aspects of internalized stigma in PLHIV. The study included 400 PLHIV receiving care in Bangkok and Chiang Mai, Thailand. Data were analyzed using descriptive statistics, Mann-Whitney U test, and Spearman correlation coefficients. The results indicated the PLHIV with mild depression had lower median scores for the social relationship internalized stigma subscale than PLHIV with major depressive disorder (p = 0.009). Total HIV internalized stigma scores were significantly correlated with PHQ-9 scores in the mild depression group (r = 0.327, p = 0.004). Depression and internalized stigma were prevalent and associated, especially in the area of social relationships. Health personnel should be aware of possible depression in PLHIV who have internalized stigma. Intervention to promote understanding and social support for PLHIV is warranted.

Stigma, HIV Risk, and Access to HIV Prevention and Treatment Services Among Men Who have Sex with Men (MSM) in the United States: A Scoping Review

In light of recent advances in HIV prevention and treatment, we reviewed the literature to understand how different types of stigma impact HIV risk; access to HIV prevention, care, and treatment services; and related health outcomes among men who have sex with men (MSM) in the US. We conducted a scoping literature review of observational and qualitative studies that examined stigma and HIV-related outcomes among MSM. Our search identified 5794 studies, of which 47 met the eligibility criteria and were included in the final analysis. The review suggests that stigma remains a formidable barrier to engaging in HIV prevention and treatment among both HIV-negative and HIV-positive MSM. Among the studies of HIV-positive MSM, internalized stigma was related to lower levels of treatment engagement. HIV-positive MSM in the Southern part of the US were also more likely to engage in risky sexual behavior. Perceived health care discrimination was negatively associated with PrEP awareness, particularly among HIV-negative Black MSM. Among young MSM of color, intersectional stigma compounded the social structural barriers to PrEP adherence. Findings indicate that stigma reduction interventions should be implemented in diverse MSM communities to address the disproportionate burden of HIV along with critical gap in the care continuum. Further research should examine how individual types of stigma, including intersectional stigma, affect viral suppression and PrEP uptake and adherence, especially among MSM of color.

Psychometric evaluation of a new drug-resistant tuberculosis stigma scale

OBJECTIVES

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

STUDY DESIGN AND SETTING

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

RESULTS

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

CONCLUSION

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

Is Perceived Stigma in Clinical Settings Associated With Poor Health Status Among New York City's Residents of Color?

OBJECTIVES

Our objectives were to assess rates of perceived stigma in health care (clinical) settings reported by racially diverse New York City residents and to examine if this perceived stigma is associated with poorer physical and mental health outcomes.

METHODS

We analyzed data from the 2016 New York City Community Health Survey. We applied bivariable and multivariable methods to assess rates of perceived stigma, and perceived stigma's statistical relationship with health care access, physical health status, and mental health status controlling for sociodemographics and health insurance status.

RESULTS

Perceived stigma was associated with poorer health care access [odds ratio (OR)=7.07, confidence interval (CI)=5.32-9.41), depression (OR=3.80, CI=2.66-5.43), diabetes (OR=1.86, CI=1.36-2.54), and poor overall general health (OR=0.43, CI=0.33-0.57). Hispanic respondents reported the highest rate of perceived stigma among racial and ethnic minority groups (mean=0.07, CI=0.05-0.08).

CONCLUSIONS

We found that perceived stigma in health care settings was a potential barrier to good health. Prior studies have illustrated that negative health outcomes are common for patients who avoid or delay care; thus, the unfortunate conclusion is that even in a diverse, heterogeneous community, stigma persists and may negatively affect well-being. Therefore, eliminating stigma in clinical settings should be a top priority for health care providers and public health professionals seeking to improve health equity.

Predictors of anxiety and depression among newly diagnosed people living with HIV: A longitudinal study

This longitudinal study examined whether past resilience and internalized stigma predicted anxiety and depression among newly diagnosed Spanish-speaking people living with HIV (PLWH). We also analyzed whether coping strategies mediated this relationship. Data were collected at two time points from 119 PLWH. Approximately a third of participants had scores indicative of anxiety symptoms, the same result was found for depressive symptoms. Structural equations modeling revealed that 61% of the variance of anxiety and 48% of the variance of depression 8 months after diagnosis was explained by the proposed model, which yielded a good fit to data. Anxiety and depressive symptoms were significantly and negatively predicted by positive thinking, thinking avoidance, and past resilience, and positively predicted by self-blame. Additionally, anxiety was positively predicted by internalized stigma. Past resilience negatively predicted internalized stigma, self-blame, and thinking avoidance and it positively predicted positive thinking. Internalized stigma positively predicted self-blame. Moreover, internalized stigma had a significant indirect effect on anxiety symptoms through self-blame, and past resilience had significant indirect effects on anxiety symptoms and depressive symptoms through internalized stigma and coping. The results point to the need for clinicians and policy makers to conduct systematic assessments and implement interventions to reduce internalized stigma and train people living with HIV to identify and use certain coping behaviors.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HIV/AIDS-related stigma, immediate families, and proactive coping processes among a clinical sample of people living with HIV/AIDS in Philadelphia, Pennsylvania

People living with HIV/AIDS (PLWHA) engage in proactive coping behaviors to minimize the risk of interpersonal stigma. This study explores proactive coping processes in navigating HIV/AIDS-related stigma within immediate families. Data for this study come from 19 one-on-one, qualitative interviews with a diverse, clinical sample of PLWHA in Philadelphia, PA. Thematic analysis indicated that participants continue to experience enacted, anticipated, and internalized forms of HIV/AIDS-related stigma. Participants discussed status concealment and selective disclosure as proactive coping resulting from anticipated stigma and physical distancing as proactive coping motivated by internalized HIV/AIDS-related stigma. Study findings demonstrate how living with a stigmatized condition can affect PLWHA social interactions with close networks like immediate families, specifically in eliciting stigma-avoidant behaviors. Anti-stigma efforts that educate immediate families to overcome stigmatizing attitudes and provide HIV-positive family members with high-quality social support should be coupled with efforts that target health-promotive self-management strategies for PLWHA.

A Comparison of Two Case Studies Using the Roy Adaptation Model: Parents of Opioid-Dependent Adults and Bariatric Surgery

The authors in this paper demonstrate the utility and versatility of the Roy Adaptation Model (RAM) as applied to two contemporary case studies. The first case uses the RAM model to gain understanding and guide nursing practice to assist the parents of a young adult with an opioid use disorder and depression, and the second case involves using the RAM model to help a woman who recently had bariatric surgery cope and adapt postoperatively in a way that helps her maximize the benefits of having had that procedure. The authors discuss how the RAM provides a holistic approach that can be used to provide high-quality, comprehensive nursing.

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

BACKGROUND

Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions.

METHODS

We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations.

RESULTS

Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes.

CONCLUSIONS

Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs.

Longitudinal Stigma Reduction in People Living with HIV Experiencing Homelessness or Unstable Housing Diagnosed With Mental Health or Substance Use Disorders: An Intervention Study

Objectives. To assess changes in perceived external stigma among people living with HIV (PLWH) experiencing homelessness or unstable housing diagnosed with mental health or substance use disorders following an intervention including care coordination and navigation assistance, building trusting relationships, addressing unmet needs, and reducing barriers to seeking and engaging in care.Methods. This study was part of a national multisite intervention project delivered at 6 geographically diverse sites throughout the United States from September 2013 through February 2017. Participant surveys were conducted at baseline, 6 months, and 12 months. We assessed perceived external stigma, defined as people's beliefs about others' attitudes toward them, related to HIV, homelessness, mental health disorders, and substance use disorders with modified stigma scales.Results. A total of 548 individuals participated. At baseline, more participants reported experiencing any perceived external HIV stigma (81%) than any stigma related to homelessness and mental health or substance use disorders (38.9%). Over time, those reporting any HIV stigma decreased significantly from baseline (81%) to 61.4% and 57.8% at 6 and 12 months, respectively.Conclusions. PLWH experiencing homelessness or unstable housing with mental health or substance use disorders are impacted by multilayered stigma. Interventions to engage them in care may help reduce stigma.

Transgender Women's Experiences with Stigma, Trauma, and Attempted Suicide in the Dominican Republic

Studies on attempted suicide in transgender populations, particularly those in resource-limited settings, are scarce. We examined the relationships between stigma, trauma, and suicide attempts in a national sample of transgender women from the Dominican Republic. Bivariate analysis examined differences between suicide attempters and nonattempters (n = 298). Multivariate analysis reported odds ratios with attempted suicide as the outcome (n = 260). About a quarter of respondents (23.9%) experienced sexual abuse, 12.3% were tortured, and 20.3% experienced a murder attempt. More than a quarter reported using illegal drugs. Independent sample t tests found significant differences between suicide attempters and nonattempters. Attempters were more likely to have experienced sexual abuse, psychological abuse, torture, and a murder attempt (p < .001 for all). Respondents who experienced psychological abuse had over three times higher odds of attempting suicide, compared to respondents who had not (OR = 3.203, p < .01). Experience with torture and attempted murder were associated with higher odds of attempting suicide (OR = 2.967, p < .05 and OR = 2.894, p < .05, respectively). Although some nations have implemented antidiscrimination policies protecting transgender citizens, these policies are often not consistently enforced. Eliminating stigmatizing policies may reduce rates of negative health outcomes and subsequently improving population health.

Development and validation of a scale to assess attitudes of health care providers towards persons affected by leprosy in southern India

INTRODUCTION

Assessment of attitudes of health care professionals is important as negative attitude could constitute a major deterrent to care-seeking by persons affected by neglected tropical diseases (NTDs) such as leprosy. Leprosy continues to pose a major disease burden in India with an annual new case detection rate of 10.17 per 100,000 population. This paper reports on the development and validation of a culturally appropriate scale to measure attitude of health care providers (HCPs) towards persons affected by leprosy in Tamil Nadu, India.

METHODOLOGY/PRINCIPAL FINDINGS

The Affective, Behavioural and Cognitive (ABC) model of attitudes guided the development of the scale. Steps in scale development included qualitative interviews and focus group discussions with medical officers and paramedical staff selected from high prevalence districts in Tamil Nadu, India which informed the development of the draft scale. Reviews of existing attitude questionnaires in related areas further contributed to scale development and together helped to generate a large pool of items which was then subjected to Thurston's scaling method for selection of items from this pool. Face and content validity were obtained, following which internal consistency and test, re-test reliability were assessed. Scaling exercise resulted in 11 items being discarded from an initial pool of 38, owing to the poor agreement among experts regarding relevance. Face and content validity were good with experts endorsing relevance and applicability of items. The intra-class correlation coefficient (ICC) for test re-test reliability of the 27 item scale was 0.6 (95% CI: 0.20-0.78) indicating marginal intra-class correlation. The overall Cronbach's alpha was 0.85 while the alphas for each of the affective and behavioural components was good at 0.78 and 0.69 respectively indicating a good degree of consistency and homogeneity between items but the alpha for the cognitive component was low at 0.53.

CONCLUSIONS

The ABC model of attitudes guided the development of the scale, ensured a mix of 27 items tapping into the three domains of Affect, Behaviour and Cognition which best explained the attitude construct. With good validity and alphas for each of the affective, behavioural components and overall alpha estimates, this scale can be a valuable tool to provide accurate estimates of the true attitudes held by HCPs. This, in turn, would be useful to obtain insights for appropriate intervention programmes that would help change negative attitudes of HCPs towards persons affected by leprosy. With some adaptations, the scales can be validated for other NTDs as well.

Impacts of HIV Stigma on Psychosocial Well-Being and Substance Use Behaviors Among People Living With HIV/AIDS In China: Across the Life Span

To date, existing studies have indicated that stigma against people living with HIV/AIDS (PLWHA) negatively affects their psychosocial well-being, and the impact may differ by age. In the current study, we aim to assess the impact of various types of stigma on PLWHA's psychological status and concomitant substance use. We explored different types of HIV stigma with psychosocial well-being and substance use employing mixed effect models among 2,987 Chinese PLWHA. Multivariate analyses revealed that each type of HIV stigma is positively associated with psychosocial distress, but negatively related to resilience and self-esteem across all age groups of PLWHA, with enacted stigma showing the strongest impact. Stigmatized PLWHA are more likely to smoke and use drugs, especially among the < 35 and 35-49-year-old groups. Age-specific interventions should be implemented to enhance PLWHA's stigma coping skill for improving their psychological health and reducing substance use in China and worldwide.

A structural equation model of perceived and internalized stigma, depression, and suicidal status among people living with HIV/AIDS

Background

Previous studies have shown positive association between HIV-related stigma and depression, suicidal ideation, and suicidal attempt among people living with HIV/AIDS (PLWH). But few studies have examined the mechanisms among HIV-related stigma, depression, and suicidal status (suicidal ideation and/or suicidal attempt) in PLWH. The current study examined the relationships among perceived and internalized stigma (PIS), depression, and suicidal status among PLWH in Guangzhou, China using structural equation modeling.

Methods

Cross-sectional study by convenience sampling was conducted and 411 PLWH were recruited from the Number Eight People’s Hospital from March to June, 2013 in Guangzhou, China. Participants were interviewed on their PIS, depressive symptoms, suicidal status, and socio-demographic characteristics. PLWH who had had suicidal ideation and suicidal attempts since HIV diagnosis were considered to be suicidal. Structural equation model was performed to examine the direct and indirect associations of PIS and suicidal status. Indicators to evaluate goodness of fit of the structural equation model included Chi-square Statistic, Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), Standardized Root Mean Square Residual (SRMR), and Weighted Root Mean Square Residual (WRMR).

Results

More than one-third (38.4%) of the PLWH had depressive symptoms and 32.4% reported suicidal ideation and/or attempt since HIV diagnosis. The global model showed good model fit (Chi-square value = 34.42, CFI = 0.98, RMSEA = 0.03, WRMR = 0.73). Structural equation model revealed that direct pathway of PIS on suicidal status was significant (standardized pathway coefficient = 0.21), and indirect pathway of PIS on suicidal status via depression was also significant (standardized pathway coefficient = 0.24). There was a partial mediating effect of depression in the association between PIS and suicidal status.

Conclusions

Our findings suggest that PIS is associated with increased depression and the likelihood of suicidal status. Depression is in turn positively associated with suicidal status and plays a mediating role between PIS and suicidal status. Therefore, to reduce suicidal ideation and attempt in PLWH, targeted interventions to reduce PIS and improve mental health status of PLWH are warranted.

Predictors of Resilience and Posttraumatic Growth Among People Living with HIV: A Longitudinal Study

This longitudinal study investigated the predictors of HIV-related resilience (HR) and posttraumatic growth (PTG) among Spanish-speaking HIV-positive people. Perceived past resilience, internalised stigma, and coping strategies were hypothesised as possible predictors. Data were collected at two time points from 119 HIV-positive people. Path analyses with latent variables revealed that half of HR 8 months after diagnosis was predicted by rumination, emotional expression, positive thinking, internalised stigma, and perceived past resilience. The latter three, along with isolation, self-blame, thinking avoidance, and help seeking predicted some PTG dimensions 8 months after diagnosis. The results highlight the importance of internalised stigma associated with HIV infection and of the differential use of coping strategies, and point to the need for clinicians and policy makers to implement stigma reduction and appropriate coping strategies interventions.

Transgender Women's Drug Use in the Dominican Republic

Purpose: Studies on drug use in transgender populations, particularly those in resource-limited settings, are scarce. Considering that drug use can be a coping mechanism to deal with stigma and traumatic experiences, we examined associations between stigma, trauma, and drug use in a national sample of transgender women from the Dominican Republic. Methods: Bivariate analyses examined differences between drug users and abstainers (n=287). Multivariate analyses reported odds ratios (OR) with general drug, marijuana, and cocaine use as outcomes (n=243). Results: A quarter of respondents (24.5%) experienced sexual abuse, 12.1% were tortured, and 20.1% experienced a murder attempt. More than a quarter reported using illegal drugs (26.1%). Drug users had lower socioeconomic status; 30.0% of drug users had a primary level of education or less (18.2% of abstainers) and 17.6% of drug users had higher income, defined as greater than 10,001 pesos (∼$210 United States Dollars, USD) per month (28.1% of abstainers). More than half of drug users experienced some form of trauma (51.4%) compared to 43.5% of abstainers, and 28.4% of drug users, compared to 17.1% of abstainers, experienced a murder attempt on her life. Independent sample t-tests found significant differences between drug users and abstainers. Transgender women who experienced sexual abuse had three times high odds of using cocaine. Drug users were more likely to have experienced sexual abuse and attempted suicide (p<0.05 for both). Respondents who attempted suicide had higher odds of using drugs generally and using marijuana specifically, compared to respondents who had not attempted suicide (OR=2.665 and 3.168, respectively). Higher scores on the stigma scale were associated with higher odds of any drug use and cocaine use (OR=1.132 and 1.325, respectively). Conclusions: Although some nations have implemented antidiscrimination policies protecting transgender citizens, these policies are not consistently enforced. Eliminating stigma and stigmatizing policies may reduce rates of drug use as a coping mechanism.

Interpersonal Mechanisms Contributing to the Association Between HIV-Related Internalized Stigma and Medication Adherence

Previous research suggests that people living with HIV (PLWH) sometimes internalize HIV-related stigma existing in the community and experience feelings of inferiority and shame due to their HIV status, which can have negative consequences for treatment adherence. PLWH's interpersonal concerns about how their HIV status may affect the security of their existing relationships may help explain how internalized stigma affects adherence behaviors. In a cross-sectional study conducted between March 2013 and January 2015 in Birmingham, AL, 180 PLWH recruited from an outpatient HIV clinic completed previously validated measures of internalized stigma, attachment styles, and concern about being seen while taking HIV medication. Participants also self-reported their HIV medication adherence. Higher levels of HIV-related internalized stigma, attachment-related anxiety (i.e., fear of abandonment by relationship partners), and concerns about being seen by others while taking HIV medication were all associated with worse medication adherence. The effect of HIV-related internalized stigma on medication adherence was mediated by attachment-related anxiety and by concerns about being seen by others while taking HIV medication. Given that medication adherence is vitally important for PLWH to achieve long-term positive health outcomes, understanding interpersonal factors affecting medication adherence is crucial. Interventions aimed at improving HIV treatment adherence should address interpersonal factors as well as intrapersonal factors.

Internalized HIV Stigma and Disclosure Concerns: Development and Validation of Two Scales in Spanish-Speaking Populations

Internalized stigma and disclosure concerns are key elements for the study of mental health in people living with HIV. Since no measures of these constructs were available for Spanish population, this study sought to develop such instruments, to analyze their reliability and validity and to provide a short version. A heterogeneous sample of 458 adults from different Spanish-speaking countries completed the HIV-Internalized Stigma Scale and the HIV-Disclosure Concerns Scale, along with the Hospital Anxiety and Depression Scale, Rosenberg's Self-esteem Scale and other socio-demographic variables. Reliability and correlation analyses, exploratory factor analyses, path analyses with latent variables, and ANOVAs were conducted to test the scales' psychometric properties. The scales showed good reliability in terms of internal consistency and temporal stability, as well as good sensitivity and factorial and criterion validity. The HIV-Internalized Stigma Scale and the HIV-Disclosure Concerns Scale are reliable and valid means to assess these variables in several contexts.

Stigma against People Living with HIV/AIDS in China: Does the Route of Infection Matter?

In the current study, we tested the hypothesis that people who contracted HIV from “blameless” routes (e.g., blood transfusion, sex with stable partners) are less stigmatized compared to people who contracted HIV from “blamable” routes (e.g., injection drug use, sex with sex workers). A cross-sectional study was conducted among 2,987 participants in Guangxi province, China, between 2012 and 2013. We employed both explanatory and predictive modeling strategy by using multivariate linear regression models. In the explanatory models, we assessed the association between routes of infection and three types of stigma (perceived, internalized, and enacted). From identified routes of infection that significantly contributed to higher stigma, we employed predictive modeling to explore predictors for the specific type of stigma. Multiple-imputation was employed for sensitivity analyses. Of the total sample, 63% were male and the average age was 42.9 years (ranged between 18 and 88). Multivariate regression models revealed that contraction from commercial sex increased the perceived (β = 0.46, 95%CI = 0.02, 0.90) and internalized stigma (β = 0.60, 95%CI = 0.09, 1.10), while injecting drug use increased the perceived (β = 0.65, 95%CI = 0.07, 1.22) and enacted stigma (β = 0.09, 95%CI = 0.02, 0.16) after controlling for confounders. Among PLWHA who were infected via commercial sex partners, social support was negatively associated with perceived (β = -0.47, 95%CI = -0.79, -0.14) and internalized stigma (β = -0.80, 95%CI = -1.24, -0.35). Among PLWHA who were infected via injecting drugs, no adherence to antiretroviral treatment (β = 0.41, 95%CI = 0.01, 0.82) was positively associated with perceived stigma, and disclosure of serostatus to others was negatively associated with enacted stigma (β = -0.20, 95%CI = -0.34, -0.05). Knowledge of the association between routes of infection and stigma can guide health professionals and policy makers to develop tailored intervention strategies to mitigate the effects of stigma and enhance HIV care utilization among PLWHA in China.

Emotional, physical and financial burdens of stigma against people living with HIV/AIDS in China

Numerous researches have shown pernicious effects of stigma against people living with HIV/AIDS (PLWHA). However, no available studies have reported these negative effects including emotional, physical to financial burdens to PLWHA. In the current study, we aim to explore different types of stigma (e.g., perceived, internalized and enacted) and the relevant consequences among PLWHA in China. A cross-sectional study was conducted from 2012 to 2013 in the Guangxi Autonomous Region in China. The validated Berger HIV Stigma Scale was used to measure various types of stigma. We employed a series of linear, logistic and polytomous regression models to assess the association between stigma and different consequences while accounting for potential confounders for each specific model. Of the total sample, 2987 PLWHA provided valid responses with 63% being male and having an average age of 42.9 years. Perceived, internalized and enacted HIV stigma were prevalent among participants, and resulted in various burdens with different magnitudes in their life contexts. Specially, PLWHA who reported higher perceived and internalized stigma were more likely to be imposed on emotional and physical burdens (p < .05). People who reported higher enacted stigma had heavier financial burden compared to their peers (p < .05). Our findings revealed that devastating consequences of HIV-related stigma in China. The prevalent stigmatizing attitudes have pushed PLWHA to the fringes of society and affected them at multiple aspects in their life context. We call for tailored efforts to overcome stigma and discrimination against PLWHA.

The impact of an indigenous proverb on women's mental health: A phenomenological approach

BACKGROUND

Proverbs and idioms represent cultural and societal beliefs and values inherited from the forefathers. An example is lebitla la mosadi ke bogadi. Over many decades African people have used such ancient instructions to counsel women to be resilient in their marriages thus impacting on their mental health.

OBJECTIVE

The purpose of this article was to explore and describe that proverb and its impact on women's mental health.

METHOD

Hermeneutic phenomenology was used to explore and describe the prover band its impact on indigenous women's mental health. The population included married, divorced, widowed and single women who were attending social clubs or networks in the cities of Tshwane and Johannesburg. Snowball and purposive sampling was used to select 57 participants. Five face-to-face interviews and eight focus groups interviews were conducted. Colaizzi's data analysis method was used to analyse data.

RESULTS

Oppression and stigmatisation of women and their families and harmful effects that may result in death were identified as having an impact on women's mental health. Some women shared that they were oppressed in many ways. In addition, they feared stigmatisation should they wish to divorce. They constantly lived in fear of being harmed or killed by their spouses.

CONCLUSION

There was a need for nurses to develop awareness regarding cultural issues so that women are better served in primary healthcare settings. Women who are suspected of experiencing abuse, should be screened for abuse so that they can be assisted accordingly.

Metacognitions mediate HIV stigma and depression/anxiety in men who have sex with men living with HIV

The study examined whether the relationships between HIV stigma and depression and anxiety would be mediated by metacognitive beliefs and thought control strategies in men who have sex with men living with HIV. Men who have sex with men living with HIV completed an online survey that measured 30-item Metacognitions Questionnaire, thought control strategies (Thought Control Questionnaire), as well as symptoms of depression (Patient Health Questionnaire-9) and anxiety (generalized anxiety disorder-7). The relationships between internalised and anticipated HIV stigma with depressive symptoms were mediated by Negative Metacognitive Beliefs and the use of Worry and Social thought control strategies. Negative Metacognitive Beliefs mediated the association between internalised HIV stigma and anxiety symptoms.

A mixed-methods approach to understanding barriers to postpartum retention in care among low-income, HIV-infected women

Optimal retention in HIV care postpartum is necessary to benefit the health and wellbeing of mothers and their infants. However, postpartum retention in HIV care among low-income women is suboptimal, particularly in the Southern United States. A mixed-methods study was conducted to identify factors associated with postpartum retention in care among HIV-infected women. Participants (n=35) were recruited during pregnancy at two county clinics and completed self-report demographic and psychosocial surveys. Twenty-two women who returned for a postpartum appointment completed a semi-structured interview about lifestyle factors and retention in care. Of the participants enrolled at baseline, 71.4% completed a follow-up with an obstetrician (OB), while 57.1% completed a follow-up with a primary care physician (PCP). High CD4 count at delivery, low viral load at baseline, low levels of depression, high interpersonal social support, and fewer other children were significantly associated with completion of postpartum follow-up. Barriers and facilitators to retention identified during qualitative interviews included competing responsibilities for time, lack of social support outside of immediate family members, limited transportation access, experiences of institutionalized stigma, knowledge about the benefits of adherence, and strong relationships with healthcare providers. OB and PCP follow-up postpartum was suboptimal in this sample. Findings underscore the importance of addressing depressive symptoms, social support, viral suppression, competing responsibilities for time, institutionalized stigma, and transportation issues in order to reduce the barriers that inhibit women from seeking postpartum HIV care.