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Birger L, Benyamini Y, Goor Y, Sahar Z, Peled E. Reproductive healthcare utilization for women in the sex trade: a qualitative study. Isr J Health Policy Res 2024; 13:43. [PMID: 39223622 PMCID: PMC11367886 DOI: 10.1186/s13584-024-00627-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/09/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Women in the sex trade encounter significant challenges in obtaining reproductive healthcare. Reports of reproductive healthcare for women in the sex trade center on the prevention and termination of pregnancies, yet most women in the sex trade globally experience full term pregnancies and bear children. This study aimed to explore barriers and enabling factors to providing reproductive healthcare for women in the sex trade in Israel. METHODS We conducted a qualitative study utilizing a grounded theory method. Data were collected through semi-structured interviews, conducted between June 2021 and July 2022. Interviews were conducted with practitioners in healthcare settings (n = 20), practitioners in social services settings (n = 15), and women in the sex trade who received reproductive health care-related medical services (n = 13) in Israel. The interviews were audiotaped, transcribed, and thematically analyzed. RESULTS The findings indicated a multilayered structure of healthcare system-related factors and women-related factors. Stigma was noted as a multidimensional barrier, reflected in service providers' attitude towards women in the sex trade, impairing the patient-provider relationship and impeding women's help-seeking. However, the creation of a relationship of trust between the women and healthcare providers enabled better health outcomes. CONCLUSIONS Based on the findings, we propose recommendations for designing and implementing reproductive healthcare services for women in the sex trade. The recommendations offer to (a) include women with lived experiences in planning and providing reproductive healthcare services, (b) adopt a trauma-informed approach, (c) emphasize nonjudgmental care, (d) train healthcare providers to reduce stigma and bias, and (e) enhance the affordability of health services for women experiencing marginalization.
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Affiliation(s)
- Lior Birger
- Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel.
| | - Yael Benyamini
- Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Goor
- The Ministry of Health, Jerusalem, Israel
| | | | - Einat Peled
- Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel
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Birger L, Peled E, Benyamini Y. Stigmatizing and inaccessible: The perspectives of female sex workers on barriers to reproductive healthcare utilization - A scoping review. J Adv Nurs 2024; 80:2273-2289. [PMID: 38069507 DOI: 10.1111/jan.16010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/02/2023] [Accepted: 11/26/2023] [Indexed: 05/12/2024]
Abstract
AIM To systematically map the extent, range and nature of qualitative studies that explored female sex workers' own perspectives on barriers to accessing reproductive healthcare services. DESIGN A scoping review of the literature utilizing Arksey and O'Malley's method. DATA SOURCES/REVIEW METHODS A search of the electronic databases MEDLINE/ PubMed, PsycNET, Sociological Abstracts, ProQuest, ScienceDirect, HeinOnline, Scopus, Web of Science and Google Scholar was conducted for items published in English between 2001 and 2021. RESULTS Twenty-one studies were included in the review, the majority of which were conducted in lower-middle-income countries. RHC themes studied were diverse, with a few more studies focusing on STI/HIV, contraceptive use and pregnancy than those focusing on childbirth and postnatal care. The findings indicate barriers in four main domains: socio-legal barriers, health services-related barriers, interpersonal barriers and personal history-related barriers. Stigma was a major multifaceted barrier. CONCLUSION Female sex workers experience exclusion in utilizing reproductive healthcare services globally. As such, healthcare services are advised to adopt a nonjudgemental approach, to enhance physical accessibility and to train nurses and other healthcare professionals on reproductive health needs of female sex workers. Finally, knowledge production processes on the RHC of FSW should adopt a holistic view of FSW, by exploring their needs and barriers related to childbirth and maternity care and by including the perspectives of FSW in high-income countries. IMPACT The review offered an in-depth understanding of female sex workers' own perspectives regarding needs and barriers in utilizing reproductive healthcare services. Findings indicated socio-legal barriers, health services-related barriers, interpersonal barriers and personal history-related barriers. The review could inform the training of nurses and other healthcare professionals in reproductive healthcare services globally. Researchers should adopt a holistic view of female sex workers, by exploring their family planning needs, including barriers related to childbirth, maternity and postpartum care. REPORTING METHOD We adhered to the EQUATOR guidelines PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation.
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Affiliation(s)
- Lior Birger
- The Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel
| | - Einat Peled
- The Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Benyamini
- The Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel
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Pulerwitz J, Gottert A, Tun W, Eromhonsele AF, Oladimeji PL, Shoyemi E, Akoro M, Ndeloa C, Adedimeji A. Reducing stigma and promoting HIV wellness/mental health of sexual and gender minorities: RCT results from a group-based programme in Nigeria. J Int AIDS Soc 2024; 27:e26256. [PMID: 38837614 PMCID: PMC11151009 DOI: 10.1002/jia2.26256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 04/15/2024] [Indexed: 06/07/2024] Open
Abstract
INTRODUCTION High levels of HIV stigma as well as stigma directed towards sexual and/or gender minorities (SGMs) are well documented in the African setting. These intersecting stigmas impede psychosocial wellbeing and HIV prevention and care. Yet, there are few if any evidence-based interventions that focus on reducing internalized stigma and promoting mental health and HIV wellness for SGMs in Africa. We developed and evaluated a group-based intervention drawing on cognitive behavioural therapy (CBT) strategies for men who have sex with men (MSM) and transgender women (TGW) at risk for or living with HIV in Lagos, Nigeria. METHODS The intervention comprised four weekly in-person group sessions facilitated by community health workers. We conducted a delayed intervention group randomized controlled trial (April-September 2022), with pre-post surveys plus 3-month follow-up (immediate group only), as well as qualitative research with participants and programme staff. Outcomes included internalized stigma related to SGM and HIV status, depression, resiliency/coping and pre-exposure prophylaxis (PrEP)/HIV treatment use. RESULTS Mean age of the 240 participants was 26 years (range 18-42). Seventy-seven percent self-identified as MSM and 23% TGW; 27% were people with HIV. Most (88%) participants attended all four sessions, and 98% expressed high intervention satisfaction. There was significant pre-post improvement in each psychosocial outcome, in both the immediate and delayed arms. There were further positive changes for the immediate intervention group by 3-month follow-up (e.g. in intersectional internalized stigma, depression). While baseline levels of ever-PrEP use were the same, 75% of immediate-group participants reported currently using PrEP at 3 months post-intervention versus 53% of delayed-group participants right after the intervention (p<0.01). Participants post-intervention described (in qualitative interviews) less self-blame, and enhanced social support and resilience when facing stigma, as well as motivation to use PrEP, and indicated that positive pre-intervention changes in psychosocial factors found in the delayed group mainly reflected perceived support from the study interviewers. CONCLUSIONS This study demonstrated the feasibility and acceptability of a group-based CBT model for MSM and TGW in Nigeria. There were also some indications of positive shifts related to stigma, mental health and PrEP, despite issues with maintaining the randomized design in this challenging environment.
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Affiliation(s)
- Julie Pulerwitz
- Social and Behavioural Science Research DivisionPopulation CouncilWashingtonDCUSA
| | - Ann Gottert
- Social and Behavioural Science Research DivisionPopulation CouncilWashingtonDCUSA
| | - Waimar Tun
- Social and Behavioural Science Research DivisionPopulation CouncilWashingtonDCUSA
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Nxumalo CT, Luvuno Z, Chiya WH, Ngcobo SJ, Naidoo D, Zamudio-Haas S, Harris O. Designing Implementation Strategies for the Inclusion of Lesbian, Gay, Bisexual, Transgender, Intersex, Queer, and Allied and Key Populations' Content in Undergraduate Nursing Curricula in KwaZulu-Natal, South Africa: Protocol for a Multimethods Research Project. JMIR Res Protoc 2024; 13:e52250. [PMID: 38598816 PMCID: PMC11179011 DOI: 10.2196/52250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/30/2023] [Accepted: 01/24/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Lesbian, gay, bisexual, transgender, intersex, queer, and allied (LGBTQIA+) individuals encounter challenges with access and engagement with health services. Studies have reported that LGBTQIA+ individuals experience stigma, discrimination, and health workers' microaggression when accessing health care. Compelling evidence suggests that the LGBTQIA+ community faces disproportionate rates of HIV infection, mental health disorders, substance abuse, and other noncommunicable diseases. The South African National Strategic Plan for HIV or AIDS, tuberculosis, and sexually transmitted infections, 2023-2028 recognizes the need for providing affirming LGBTQIA+ health care as part of the country's HIV or AIDS response strategy. However, current anecdotal evidence suggests paucity of LGBTQIA+ and key populations' health content in the undergraduate health science curricula in South Africa. Moreover, literature reveals a general lack of health worker training regarding the health needs of LGBTQIA+ persons and other key populations such as sex workers, people who inject drugs, and men who have sex with men. OBJECTIVE This study aimed to describe the design of a project that aims at facilitating the inclusion of health content related to the LGBTQIA+ community and other key populations in the undergraduate nursing curricula of KwaZulu-Natal, South Africa. METHODS A multimethods design encompassing collection of primary and secondary data using multiple qualitative designs and quantitative approaches will be used to generate evidence that will inform the co-design, testing, and scale-up of strategies to facilitate the inclusion of LGBTQIA+ and key populations content in the undergraduate nursing curricula in KwaZulu-Natal, South Africa. Data will be collected using a combination of convenience, purposive, and snowball sampling techniques from LGBTQIA+ persons; academic staff; undergraduate nursing students; and other key populations. Primary data will be collected through individual in-depth interviews, focus groups discussions, and surveys guided by semistructured and structured data collection tools. Data collection and analysis will be an iterative process guided by the respective research design to be adopted. The continuous quality improvement process to be adopted during data gathering and analysis will ensure contextual relevance and sustainability of the resultant co-designed strategies that are to be scaled up as part of the overarching objective of this study. RESULTS The proposed study is designed in response to recent contextual empirical evidence highlighting the multiplicity of health challenges experienced by LGBTQIA+ individuals and key populations in relation to health service delivery and access to health care. The potential findings of the study may be appropriate for contributing to the education of nurses as one of the means to ameliorate these problems. Data collection is anticipated to commence in June 2024. CONCLUSIONS This research has potential implications for nursing education in South Africa and worldwide as it addresses up-to-date problems in the nursing discipline as it pertains to undergraduate students' preparedness for addressing the unique needs and challenges of the LGBTQIA+ community and other key populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/52250.
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Affiliation(s)
- Celenkosini Thembelenkosini Nxumalo
- Research Development and Postgraduate Support, Office of the DVC Research and Innovation, University of the Western Cape, Cape Town, South Africa
- Academic Development Unit, Faculty of Health Sciences, Durban University of Technology, Durban, South Africa
| | - Zamasomi Luvuno
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Wilbroda Hlolisile Chiya
- Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Silingene Joyce Ngcobo
- Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Deshini Naidoo
- Discipline of Occupational Therapy, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sophia Zamudio-Haas
- Centre for AIDS Prevention Studies, University of San Francisco California, San Francisco, CA, United States
| | - Orlando Harris
- Department of Community Health Systems, University of San Francisco California, San Francisco, CA, United States
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Mlunde LB, Saalim K, Mbwambo JK, Kiwia P, Fitch E, Manyama W, Rugemalila I, Clay S, Lambdin BH, Stelmach RD, Bann C, Nyblade L. Adapting a health facility HIV stigma-reduction participatory training intervention to address drug use stigma in HIV care and treatment clinics in Dar es Salaam, Tanzania. Harm Reduct J 2024; 21:65. [PMID: 38491349 PMCID: PMC10941424 DOI: 10.1186/s12954-024-00965-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/20/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND HIV prevalence among people who use drugs (PWUD) in Tanzania is 4-7 times higher than in the general population, underscoring an urgent need to increase HIV testing and treatment among PWUD. Drug use stigma within HIV clinics is a barrier to HIV treatment for PWUD, yet few interventions to address HIV-clinic drug use stigma exist. Guided by the ADAPT-ITT model, we adapted the participatory training curriculum of the evidence-based Health Policy Plus Total Facility Approach to HIV stigma reduction, to address drug use stigma in HIV care and treatment clinics (CTCs). METHODS The first step in the training curriculum adaptation process was formative research. We conducted 32 in-depth interviews in Dar es Salaam, Tanzania: 18 (11 men and 7 women) with PWUD living with HIV, and 14 with a mix of clinical [7] and non-clinical [7] CTC staff (5 men and 9 women). Data were analyzed through rapid qualitative analysis to inform initial curriculum adaptation. This initial draft curriculum was then further adapted and refined through multiple iterative steps of review, feedback and revision including a 2-day stakeholder workshop and external expert review. RESULTS Four CTC drug use stigma drivers emerged as key to address in the curriculum adaptation: (1) Lack of awareness of the manifestations and consequences of drug use stigma in CTCs (e.g., name calling, ignoring PWUD and denial of care); (2) Negative stereotypes (e.g., all PWUD are thieves, dangerous); (3) Fear of providing services to PWUD, and; (4) Lack of knowledge about drug use as a medical condition and absence of skills to care for PWUD. Five, 2.5-hour participatory training sessions were developed with topics focused on creating awareness of stigma and its consequences, understanding and addressing stereotypes and fears of interacting with PWUD; understanding drug use, addiction, and co-occurring conditions; deepening understanding of drug use stigma and creating empathy, including a panel session with people who had used drugs; and working to create actionable change. CONCLUSION Understanding context specific drivers and manifestations of drug use stigma from the perspective of PWUD and health workers allowed for ready adaptation of an existing evidence-based HIV-stigma reduction intervention to address drug use stigma in HIV care and treatment clinics. Future steps include a pilot test of the adapted intervention.
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Affiliation(s)
- Linda B Mlunde
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | | | - Jessie K Mbwambo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Pfiriael Kiwia
- Kimara Peer Educators and Health Promoters, Dar es Salaam, Tanzania
| | | | | | | | - Sue Clay
- 3C Regional Consultants, Lusaka, Zambia
| | | | | | - Carla Bann
- RTI International, Research Triangle Park, NC, USA
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Shen Y, Franks J, Reidy W, Olsen H, Wang C, Mushimbele N, Mazala RT, Tchissambou T, Malele F, Kilundu A, Bingham T, Djomand G, Mukinda E, Ewetola R, Abrams EJ, Teasdale CA. Pre-exposure prophylaxis uptake concerns in the Democratic Republic of the Congo: Key population and healthcare workers perspectives. PLoS One 2023; 18:e0280977. [PMID: 37917646 PMCID: PMC10621847 DOI: 10.1371/journal.pone.0280977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 10/16/2023] [Indexed: 11/04/2023] Open
Abstract
Key populations (KP) in the Democratic Republic of the Congo (DRC), including female sex workers (SW), are disproportionally affected by HIV. Quantitative feedback surveys were conducted at seven health facilities in DRC with 70 KP clients enrolled in pre-exposure prophylaxis (PrEP) services to measure benefits and concerns. The surveys also assessed satisfaction with PrEP services and experiences of stigma at the health facilities. Thirty healthcare workers (HCW) were surveyed to measure attitudes, beliefs, and acceptability of providing services to KP. KP client survey participants were primarily female SW. KP clients reported that the primary concern about taking PrEP was fear of side effects (67%) although few KP reported having experienced side effect (14%). HCW concurred with clients that experienced and anticipated side effects were a primary PrEP uptake concern, along with costs of clinic visits.
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Affiliation(s)
- Yanhan Shen
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
- Institute for Implementation Science in Population Health, CUNY SPH, New York, NY, United States of America
| | - Julie Franks
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, United States of America
| | - William Reidy
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, NY, United States of America
| | - Halli Olsen
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, United States of America
| | - Chunhui Wang
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, United States of America
| | | | | | | | | | | | - Trista Bingham
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Gaston Djomand
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Elie Mukinda
- Democratic Republic of the Congo Centers for Disease Control and Prevention, Kinshasa, DRC
| | - Raimi Ewetola
- Democratic Republic of the Congo Centers for Disease Control and Prevention, Kinshasa, DRC
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, NY, United States of America
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States of America
| | - Chloe A. Teasdale
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
- Institute for Implementation Science in Population Health, CUNY SPH, New York, NY, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, NY, United States of America
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Mwaniki SW, Kaberia PM, Mugo PM, Palanee-Phillips T. "We must help them despite who they are…": healthcare providers' attitudes and perspectives on care for young gay, bisexual and other men who have sex with men in Nairobi, Kenya. BMC Health Serv Res 2023; 23:1055. [PMID: 37789339 PMCID: PMC10546658 DOI: 10.1186/s12913-023-10026-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 09/12/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Compared to young heterosexual men, young gay, bisexual and other men who have sex with men (YMSM) face a disproportionate burden of sexual health conditions. This disparity is occasioned by factors such as criminalization and stigmatization of same-sex practices, YMSM's limited access to non-judgmental and non-discriminatory health services, and challenges associated with healthcare delivery. We explored the attitudes and perspectives of tertiary academic institution-based healthcare providers (HCPs) toward provision of services to YMSM in Nairobi, Kenya. METHODS In September 2021, six in-person focus group discussions (FGDs) were held with 36 HCPs drawn from six public tertiary academic institutions within the Nairobi metropolis. HCPs were drawn from six cadres: front office staff, nurses, clinicians, counsellors, laboratory technologists, and pharmaceutical technologists. Discussions were conducted in English, transcribed verbatim and analyzed thematically using NVivo version 12. RESULTS Analysis showed that despite expressing disapproval of same-sex practices, HCPs recognized their professional duty to provide care to YMSM, voiced challenges they experienced when providing care to YMSM, and suggested possible strategies for improving care for YMSM. Disapproval of same-sex practices mainly stemmed from HCPs' personal values, societal norms and religious beliefs, though some HCPs identified religious principles such as the golden rule of "treating others as one would want to be treated" as motivation to providing care to YMSM. HCPs did not perceive criminalization of same-sex practices as a barrier to providing care to YMSM. Healthcare delivery challenges included inadequate knowledge and skills, a desire to "convert" YMSM's perceived deviant homosexual to the normative heterosexual orientation, secondary stigma from other HCPs, and healthcare settings that did not support YMSM to disclose same-sex practices. Suggestions for improving care comprised sensitization and training of HCPs, encouraging more HCP-YMSM interaction, providing YMSM-friendly and inclusive services, and advocacy for YMSM services. CONCLUSION There is need for interventions to improve HCPs' knowledge of YMSM's health needs, build skills to respond to these needs, and foster affirming attitudes toward same-sex practices. By so doing, YMSM can hopefully be able to access services that meet their needs, and are non-discriminatory, non-stigmatizing and non-judgmental.
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Affiliation(s)
- Samuel Waweru Mwaniki
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Health Services, Administration and Campus Support Services, University of Nairobi, Nairobi, Kenya.
| | - Peter Mwenda Kaberia
- Department of Mathematics, Faculty of Science and Technology, University of Nairobi, Nairobi, Kenya
| | - Peter Mwangi Mugo
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
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Stephenson A, Calvo-Friedman A, Altshuler L, Zabar S, Hanley K. Educational training to improve opioid overdose response among health center staff: a quality improvement initiative. Harm Reduct J 2023; 20:83. [PMID: 37391790 PMCID: PMC10311901 DOI: 10.1186/s12954-023-00803-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 06/06/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND There were seven opioid overdoses in this New York City (NYC) federally qualified health center from December 2018 through February 2019, reflecting the rising rate of overdose deaths in NYC overall at the time. In response to these overdoses, we sought to increase the readiness of health center staff to recognize and respond to opioid overdoses and decrease stigmatizing attitudes around opioid use disorder (OUD). METHODS An hour-long training focusing on opioid overdose response was administered to clinical and non-clinical staff of all levels at the health center. This training included didactic education on topics such as the overdose epidemic, stigma around OUD, and opioid overdose response, as well as discussion. A structured assessment was administered immediately before and following the training to evaluate change in knowledge and attitudes. Additionally, participants completed a feedback survey immediately after the training to assess acceptability. Paired t-tests and analysis of variance tests were used to assess changes in pre- and post-test scores. RESULTS Over 76% of the health center staff participated in the training (N = 310). There were large and significant increases in mean knowledge and attitudinal scores from pre- to post-test (p < .001 and p < .001, respectively). While there was no significant effect of profession on attitudinal change scores, profession did have a significant effect on knowledge change scores, with administrative staff, non-clinical support staff, other healthcare staff, and therapists learning significantly more than providers (p < .001). The training had high acceptability among participants from diverse departments and levels. CONCLUSIONS An interactive educational training increased staff's knowledge and readiness to respond to an overdose as well as improved attitudes toward individuals living with OUD. TRIAL REGISTRATION This project was undertaken as a quality improvement initiative at the health center and as such was not formally supervised by the Institutional Review Board per their policies. Further, per the guidelines of the International Committee of Medical Journal Editors, registration is not necessary for clinical trials whose sole purpose is to assess an intervention's effect on providers.
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Affiliation(s)
- Audrey Stephenson
- NYC Health + Hospitals/Gotham Health, Gouverneur, 227 Madison St., New York, NY, 10002, USA
- West Chester University of Pennsylvania, West Chester, PA, USA
| | - Alessandra Calvo-Friedman
- NYC Health + Hospitals/Gotham Health, Gouverneur, 227 Madison St., New York, NY, 10002, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Lisa Altshuler
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Sondra Zabar
- NYC Health + Hospitals/Gotham Health, Gouverneur, 227 Madison St., New York, NY, 10002, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kathleen Hanley
- NYC Health + Hospitals/Gotham Health, Gouverneur, 227 Madison St., New York, NY, 10002, USA.
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA.
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Torrence C, Bhanu A, Bertrand J, Dye C, Truong K, Madathil KC. Preparing future health care workers for interactions with people with dementia: A mixed methods study. GERONTOLOGY & GERIATRICS EDUCATION 2023; 44:223-242. [PMID: 35393916 DOI: 10.1080/02701960.2022.2042805] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Strategies used in training future health professionals have expanded from traditional methods to a variety of approaches, including sensitivity training. Students who receive disease-specific sensitivity training are more compassionate to patients. Alzheimer's disease (AD) sensitivity training includes deficit-focused dementia tours that physically alter sensations. This embedded-experimental (between-subjects) variant mixed-methods study assessed the effectiveness of virtual reality as a delivery format for dementia tours compared to dementia tours that physically alter sensations. It also compared the effectiveness of deficit-focused dementia sensitivity training to reading strengths-focused case studies, a traditional instruction method. Forty-one university students were randomized into one of three conditions. All participants completed pre- and post-assessments and were interviewed. Quantitative results indicate that a dementia tour offered through virtual reality is as effective as a physical-based tour; however, compared to reading case studies, participants reported poorer attitudes about living with AD and feeling less prepared for caregiving. The qualitative results show an increase in empathy across all conditions. Integration of findings indicates that dementia tours in both formats are effective at encouraging empathy and that both strengths-based and deficit-based sensitivity training are important components of education for future health care workers.
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Affiliation(s)
- Caitlin Torrence
- Office of Research and Organizational Development & Department of Public Health Sciences
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Muwanguzi PA, Nabunya R, Karis VMS, Nabisere A, Nangendo J, Mujugira A. Nurses' reflections on caring for sexual and gender minorities pre-post stigma reduction training in Uganda. BMC Nurs 2023; 22:50. [PMID: 36823533 PMCID: PMC9947888 DOI: 10.1186/s12912-023-01208-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/14/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Men who have sex with men (MSM) and transgender women (TGW) have a significant HIV burden worldwide. Data from eight countries across sub-Saharan Africa found a pooled HIV prevalence of 14% among MSM and 25% among TGW. Stigma and discrimination among healthcare providers are barriers to healthcare access by these populations. We sought to explore nurses' attitudes before and after sensitivity training to reduce stigma in HIV prevention and care provision to MSM and transgender persons in Uganda. METHODS An explorative qualitative study comprising in-depth interviews. Nineteen nurses who underwent sensitivity training in caring for the vulnerable, priority and key populations in Uganda participated. We interviewed each participant before and after the stigma reduction training and analyzed the data with NVivo. RESULTS Eight (8) themes emerged from the reflections before the training, namely, 'the definition of MSM and transgender persons', 'legal concerns', 'mental illness', 'attitude in health care provision', 'personal perceptions', 'self-efficacy', 'insufficient training preparation', and 'reasons for gender or sexual orientation preference'. The post-training reflections suggested a change in knowledge and attitude. Five themes emerged for MSM: 'stigma reduction', 'sexual practices and sexuality', 'the need for tailored health approaches', 'MSM and the law' and 'corrected misconceptions'. For transmen, 'reproductive health needs', 'social needs', 'safety needs', 'Gender identity recognition' and 'reduced stigma, discrimination, and barriers to care'. Finally, the reflections on their attitudes towards transwomen were on five topics; Gender affirming care', 'Healthcare provision for transwomen', 'Need for further training', 'New knowledge acquired', and 'Sexual violence'. CONCLUSION Nurses' attitudes and empathy for vulnerable and key populations improved following the training. Nursing training programs should consider incorporating sexual and gender minority (SGM) specific health training into their curricula to decrease negative attitudes. There is a need to identify best practices and conduct implementation research to provide culturally sensitive and affirming healthcare delivery in sub-Saharan Africa. Future studies should evaluate the effect of provider sensitivity training on sexual health and HIV outcomes for SGM. Furthermore, interventions targeting higher-level stigma, such as structural and policy levels, are critical because they influence interpersonal stigma reduction efforts and initiatives.
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Affiliation(s)
- Patience A. Muwanguzi
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, P. O. Box 7072, Uganda
| | - Racheal Nabunya
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, P. O. Box 7072, Uganda
| | - Victoria M. S. Karis
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, P. O. Box 7072, Uganda
| | - Allen Nabisere
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, P. O. Box 7072, Uganda
| | - Joan Nangendo
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, P.O. BOX 7072, Uganda
| | - Andrew Mujugira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, P. O Box 22418, Uganda
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11
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Lancaster KE, Endres-Dighe S, Sucaldito AD, Piscalko H, Madhu A, Kiriazova T, Batchelder AW. Measuring and Addressing Stigma Within HIV Interventions for People Who Use Drugs: a Scoping Review of Recent Research. Curr HIV/AIDS Rep 2022; 19:301-311. [PMID: 36048310 PMCID: PMC10546998 DOI: 10.1007/s11904-022-00619-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Persistent stigma remains a crucial barrier to HIV prevention and treatment services among people who use drugs (PWUD), particularly for those living with or at-risk for HIV. This scoping review examines the current state of science with regard to approaches for measuring and addressing stigma within HIV interventions among PWUD. RECENT FINDINGS Sixteen studies fit the inclusion criteria for this review. Half the studies originated within the USA, and the remaining represented four different regions. Within these studies, stigma was measured using various quantitative, qualitative, and mixed methods. The studies primarily focused on HIV stigma, including value-based judgments, anticipated stigma, and perceived stigma domains. Information-based and skills building approaches at the individual level were the most common for the stigma reduction interventions. Adoption of systematic evaluations is needed for measuring stigma, including intersectional stigma, within HIV interventions among PWUD. Future studies should focus on developing multilevel intersectional stigma reduction interventions for PWUD with and at-risk for HIV globally.
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Affiliation(s)
| | | | - Ana D Sucaldito
- College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Hannah Piscalko
- College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Aarti Madhu
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | | | - Abigail W Batchelder
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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12
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Tun W, Pulerwitz J, Shoyemi E, Fernandez A, Adeniran A, Ejiogu F, Sangowawa O, Granger K, Dirisu O, Adedimeji AA. A qualitative study of how stigma influences HIV services for transgender men and women in Nigeria. J Int AIDS Soc 2022; 25 Suppl 1:e25933. [PMID: 35818868 PMCID: PMC9274359 DOI: 10.1002/jia2.25933] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 05/05/2022] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Transgender men and women in Nigeria experience many barriers in accessing HIV prevention and treatment services, particularly given the environment of transphobia (including harassment, violence and discrimination) and punitive laws in the country. HIV epidemic control in Nigeria requires improving access to and quality of HIV services for key populations at high risk, including transgender men and women. We assessed how stigma influences HIV services for transgender people in Lagos, Nigeria. METHODS In-depth interviews (IDIs) and focus group discussions were conducted with transgender men (n = 13) and transgender women (n = 25); IDIs were conducted with community service organization (CSO) staff (n = 8) and healthcare providers from CSO clinics and public health facilities (n = 10) working with the transgender population in March 2021 in Lagos. Content analysis was used to identify how stigma influences transgender people's experiences with HIV services. RESULTS AND DISCUSSION Three main findings emerged. First, gender identity disclosure is challenging due to anticipated stigma experienced by transgender persons and fear of legal repercussions. Fear of being turned in to authorities was a major barrier to disclose to providers in facilities not affiliated with a transgender-inclusive clinic. Providers also reported difficulty in eliciting information about the client's gender identity. Second, respondents reported lack of sensitivity among providers about gender identity and conflation of transgender men with lesbian women and transgender women with being gay or men who have sex with men, the latter being more of a common occurrence. Transgender participants also reported feeling disrespected when providers were not sensitive to their pronoun of preference. Third, HIV services that are not transgender-inclusive and gender-affirming can reinforce stigma. Both transgender men and women spoke about experiencing stigma and being refused HIV services, especially in mainstream public health facilities, as opposed to transgender-inclusive CSO clinics. CONCLUSIONS This study highlights how stigma impedes access to appropriate HIV services for transgender men and women, which can have a negative impact along the HIV care continuum. There is a need for transgender-inclusive HIV services and competency trainings for healthcare providers so that transgender clients can receive appropriate and gender-affirming HIV services.
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Affiliation(s)
- Waimar Tun
- Social and Behavioral Science Research, Population Council, Washington, DC, USA
| | - Julie Pulerwitz
- Social and Behavioral Science Research, Population Council, Washington, DC, USA
| | | | | | | | | | | | - Krista Granger
- Social and Behavioral Science Research, Population Council, Washington, DC, USA
| | - Osasuyi Dirisu
- Policy Innovation Unit, Nigerian Economic Summit Group, Lagos, Nigeria
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13
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Dzobo M, Dzinamarira T, Murewanhema G, Madziva R, Herrera H, Musuka G. Limited syphilis testing for key populations in Zimbabwe: A silent public health threat. S Afr J Infect Dis 2022; 37:385. [PMID: 35815225 PMCID: PMC9257705 DOI: 10.4102/sajid.v37i1.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 03/31/2022] [Indexed: 11/01/2022] Open
Abstract
In this article, the authors discuss the problem of high prevalences of active syphilis amongst key populations (KPs) in Zimbabwe, in combination with low testing rates, partly because of a difficult legal and social environment for these populations. The article highlights the need to develop strategies to address the high prevalence of syphilis amongst KPs. The authors discuss requirements for addressing deficits in existing clinical services, predominantly primary care settings, in providing primary healthcare, including sexually transmitted infection (STI) management, to Zimbabwe’s KP communities and utility of point-of-care testing and self-testing and other innovations to improve testing uptake.
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Affiliation(s)
- Mathias Dzobo
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Tafadzwa Dzinamarira
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Grant Murewanhema
- Unit of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Roda Madziva
- School of Sociology and Social Policy, University of Nottingham, Nottingham, United Kingdom
| | - Helena Herrera
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, United Kingdom
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14
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Dibble KE, Baral SD, Beymer MR, Stahlman S, Lyons CE, Olawore O, Ndour C, Turpin Nunez G, Toure-Kane C, Leye Diouf N, Diouf D, Drame FM, Mboup S, Murray SM. Stigma and healthcare access among men who have sex with men and transgender women who have sex with men in Senegal. SAGE Open Med 2022; 10:20503121211069276. [PMID: 35517371 PMCID: PMC9066634 DOI: 10.1177/20503121211069276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/07/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives: Cisgender gay, bisexual, and other men who have sex with men and transgender women experience HIV incidence disparities in Senegal. These analyses determined how depression and different stigma mechanisms related to sexual behavior are associated with healthcare access, sexually transmitted infection testing, and HIV testing among cisgender gay, bisexual, and other men who have sex with men and transgender women across three cities in western Senegal. Methods: Logistic regression assessed the relationship of three stigma scales (stigma from family and friends, anticipated healthcare stigma, and general social stigma) and depression with these outcomes. Results: Depression and stigma were not associated with healthcare access, sexually transmitted infection testing, or HIV testing. However, individuals who had disclosed their sexual identity to a medical provider were more likely to test for HIV. Conclusions: Sexual behavior stigma experienced by cisgender gay, bisexual, and other men who have sex with men and trans women in Senegal may not limit access to routine healthcare, but may limit disclosure of sexual orientation and practices, limiting access to appropriate HIV prevention services.
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Affiliation(s)
- Kate E Dibble
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan D Baral
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Matthew R Beymer
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Shauna Stahlman
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carrie E Lyons
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Oluwasolape Olawore
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cheikh Ndour
- Division de La Lutte Contre Le Sida et Les IST, Ministry of Health, Dakar, Senegal
| | - Gnilane Turpin Nunez
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Coumba Toure-Kane
- Molecular Biology Unit, National Reference Center for HIV and STDs, Dakar, Senegal
| | - Nafissatou Leye Diouf
- Institut de Recherche en Santé de Surveillance Epidemiologique et de Formations, Dakar, Senegal
| | | | | | - Souleymane Mboup
- Institut de Recherche en Santé de Surveillance Epidemiologique et de Formations, Dakar, Senegal
| | - Sarah M Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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15
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Bohren MA, Vazquez Corona M, Odiase OJ, Wilson AN, Sudhinaraset M, Diamond-Smith N, Berryman J, Tunçalp Ö, Afulani PA. Strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings: A mixed-methods systematic review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000582. [PMID: 36962453 PMCID: PMC10021469 DOI: 10.1371/journal.pgph.0000582] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 05/13/2022] [Indexed: 11/19/2022]
Abstract
Stigma and discrimination are fundamental causes of health inequities, and reflect privilege, power, and disadvantage within society. Experiences and impacts of stigma and discrimination are well-documented, but a critical gap remains on effective strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We aimed to address this gap by conducting a mixed-methods systematic review and narrative synthesis to describe strategy types and characteristics, assess effectiveness, and synthesize key stakeholder experiences. We searched MEDLINE, CINAHL, Global Health, and grey literature. We included quantitative and qualitative studies evaluating strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We used an implementation-focused narrative synthesis approach, with four steps: 1) preliminary descriptive synthesis, 2) exploration of relationships between and across studies, 3) thematic analysis of qualitative evidence, and 4) model creation to map strategy aims and outcomes. Of 8,262 articles screened, we included 12 articles from 10 studies. Nine articles contributed quantitative data, and all measured health worker-reported outcomes, typically about awareness of stigma or if they acted in a stigmatizing way. Six articles contributed qualitative data, five were health worker perspectives post-implementation and showed favorable experiences of strategies and beliefs that strategies encouraged introspection and cultural humility. We mapped studies to levels where stigma can exist and be confronted and identified critical differences between levels of stigma strategies aimed to intervene on and evaluation approaches used. Important foundational work has described stigma and discrimination in sexual and reproductive healthcare settings, but limited interventional work has been conducted. Healthcare and policy interventions aiming to improve equity should consider intervening on and measuring stigma and discrimination-related outcomes. Efforts to address mistreatment will not be effective when stigma and discrimination persist. Our analysis and recommendations can inform future intervention design and implementation research to promote respectful, person-centered care for all.
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Affiliation(s)
- Meghan A Bohren
- Gender and Women's Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Martha Vazquez Corona
- Gender and Women's Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Osamuedeme J Odiase
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Alyce N Wilson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
- Nossal Institute, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - May Sudhinaraset
- Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Nadia Diamond-Smith
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Jim Berryman
- Brownless Biomedical Library, University of Melbourne, Melbourne, Victoria, Australia
| | - Özge Tunçalp
- Department of Sexual and Reproductive Health and Research, including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
| | - Patience A Afulani
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America
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16
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Mujugira A, Kasiita V, Bagaya M, Nakyanzi A, Bambia F, Nampewo O, Kamusiime B, Mugisha J, Nalumansi A, Twesigye CC, Muwonge TR, Baeten JM, Wyatt MA, Tsai AC, Ware NC, Haberer JE. "You are not a man": a multi-method study of trans stigma and risk of HIV and sexually transmitted infections among trans men in Uganda. J Int AIDS Soc 2021; 24:e25860. [PMID: 34965322 PMCID: PMC8716065 DOI: 10.1002/jia2.25860] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 12/06/2021] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Transgender (trans) men in sub-Saharan Africa are a hidden and vulnerable population who may engage in sex work due to socio-economic exclusion and lack of alternative employment opportunities. Little is known about HIV and sexually transmitted infection (STI) risk among trans men in this setting. We conducted a multi-method study to characterize HIV/STI risk among trans men in Uganda. METHODS Between January and October 2020, we enrolled 50 trans men into a cross-sectional study through snowball sampling. Data were collected on socio-demographic characteristics, sexual practices and depression. We conducted 20 qualitative interviews to explore: (1) descriptions of sexual practices that could increase HIV/STI exposure; (2) experiences of accessing public healthcare facilities; (3) perceptions of HIV or STI testing; (4) HIV and STI service delivery; and (5) drug and alcohol use. We used an inductive content analytic approach centring on descriptive category development to analyse the data. RESULTS The median age was 25 years (interquartile range 23-28). The prevalence of HIV, syphilis and hepatitis B was 4%, 6% and 8%, respectively. We observed multiple levels of intersecting individual, interpersonal and structural stigmas. (1) Trans men reported transphobic rape motivated by interpersonal stigma that was psychologically traumatizing to the survivor. The resultant stigma and shame hindered healthcare access. (2) Structural stigma and economic vulnerability led to sex work, which increased the risk of HIV and other STIs. Sex work stigma further compounded vulnerability. (3) Individualized stigma led to fear of disclosure of gender identity and HIV status. Concealment was used as a form of stigma management. (4) Multiple levels of stigma hampered access to healthcare services. Preference for trans-friendly care was motivated by stigma avoidance in public facilities. Overall, the lived experiences of trans men highlight the intertwined relationship between stigma and sexual health. CONCLUSIONS In this sample from Uganda, trans men experienced stigma at multiple levels, highlighting the need for gender-sensitive healthcare delivery. Stigma reduction interventions, including provider training, non-discrimination policies, support groups and stigma counselling, could strengthen uptake and utilization of prevention services by this marginalized population.
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Affiliation(s)
- Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda.,Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Vicent Kasiita
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Monica Bagaya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Agnes Nakyanzi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Felix Bambia
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Oliva Nampewo
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Brenda Kamusiime
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jackson Mugisha
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Monique A Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Harvard Global, Cambridge, Massachusetts, USA
| | - Alexander C Tsai
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica E Haberer
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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17
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Lemons-Lyn A, Reidy W, Myint WW, Chan KN, Abrams E, Aung ZZ, Benech I, Bingham T, Desai M, Khin EE, Lin T, Olsen H, Oo HN, Wells C, Mital S. Optimizing HIV Services for Key Populations in Public-Sector Clinics in Myanmar. J Int Assoc Provid AIDS Care 2021; 20:23259582211055933. [PMID: 34821151 PMCID: PMC8640295 DOI: 10.1177/23259582211055933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Key populations, ie, female sex workers, men who have sex with men, transgender people, people who inject drugs, and people in prisons and other closed settings, experience stigma, discrimination, and structural barriers when accessing HIV prevention and care. Public health facilities in Myanmar became increasingly involved in HIV service delivery, leading to an urgent need for healthcare workers to provide client-centred, key population-friendly services. Between July 2017-June 2018, the Myanmar Ministry of Health and Sports and National AIDS Programme collaborated with ICAP at Columbia University and the US Centers for Disease Control and Prevention to implement a quasi-experimental, multicomponent intervention including healthcare worker sensitization training with pre- and post- knowledge assessments, healthcare worker and client satisfaction surveys, and structural changes. We observed modest improvements among healthcare workers (n = 50) in knowledge assessments. Classification of clients into key population groups increased and fewer clients were classified as low risk. Key population clients reported favourable perceptions of the quality and confidentiality of care through self-administered surveys. Our findings suggest public health facilities can deliver HIV services that are valued by key population clients.
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Affiliation(s)
| | | | | | - Khin N Chan
- 5798ICAP at Columbia University, Yangon, Myanmar
| | | | - Zaw Zaw Aung
- National AIDS Programme, Ministry of Health and Sports, Yangon, Myanmar
| | - Irene Benech
- 1242Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Trista Bingham
- 1242Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mitesh Desai
- 119199Centers for Disease Control and Prevention, Yangon, Myanmar
| | - Ei Ei Khin
- 119199Centers for Disease Control and Prevention, Yangon, Myanmar
| | - Tharaphi Lin
- 5798ICAP at Columbia University, Yangon, Myanmar
| | - Halli Olsen
- 560848ICAP at Columbia University, New York, USA
| | - Htun Nyunt Oo
- National AIDS Programme, Ministry of Health and Sports, Yangon, Myanmar
| | - Cassia Wells
- 560848ICAP at Columbia University, New York, USA
| | - Sasha Mital
- 1242Centers for Disease Control and Prevention, Atlanta, GA, USA
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18
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Muhindo R, Mujugira A, Castelnuovo B, Sewankambo NK, Parkes-Ratanshi R, Tumwesigye NM, Nakku-Joloba E, Kiguli J. "I felt very small and embarrassed by the health care provider when I requested to be tested for syphilis": barriers and facilitators of regular syphilis and HIV testing among female sex workers in Uganda. BMC Public Health 2021; 21:1982. [PMID: 34727898 PMCID: PMC8564957 DOI: 10.1186/s12889-021-12095-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background Periodic testing of female sex workers (FSW) for sexually transmitted infections (STIs) is a core component of global and national responses to achieve population-level STI elimination. We conducted a qualitative study to explore barriers and facilitators of regular syphilis and HIV testing among FSW in Uganda. Methods Within a quasi-experimental study among 436 FSW to assess the effect of peer education and text message reminders on uptake of regular STI and HIV testing among FSW, we conducted 48 qualitative interviews in four cities in Uganda from August–December 2018. We purposively selected FSW who tested for syphilis and HIV every 3–6 months; 12 FSW were interviewed in each city. Sex worker interviews explored: 1) reasons for periodic syphilis and HIV testing; 2) barriers and facilitators of testing; 3) experiences of testing; and 4) challenges faced while seeking testing services. Data were analyzed using thematic content analysis. Results Thematic analysis revealed individual- and health system-level barriers and facilitators of testing. For syphilis, barriers were a) interpersonal stigma, low perceived severity of syphilis and testing misconceptions (individual); and b) judgmental provider attitudes, paucity of facilities offering syphilis testing, stockouts of test kits and high cost (health system). Facilitators were c) desire to remain healthy, get married and have children, knowing the benefits of early treatment, influence of male partners/clients and normative testing behaviors (individual); and d) sex worker clinics offering dual syphilis/HIV testing (health system). For HIV, barriers included: a) internalized stigma (individual); and b) unfavorable clinic hours, stigma, discrimination, and unfriendly provider (health system). Facilitators were a) motivations to stay healthy and attract clients, habitual testing, self-efficacy, doubts about accuracy of negative test results, and use of post-exposure prophylaxis (individual); and d) availability of testing facilities (health system). Syphilis and HIV had similar testing barriers and facilitators. Conclusions HIV programs are likely to be important entry points for syphilis testing among FSW. Multi-level interventions to address testing barriers should consider focusing on these service delivery points. Extending the dual syphilis and HIV testing approach to FSW may improve testing uptake for both infections at public health facilities and decrease population-level incidence.
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Affiliation(s)
- Richard Muhindo
- Department of Nursing, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Andrew Mujugira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.,School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Barbara Castelnuovo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nelson K Sewankambo
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rosalind Parkes-Ratanshi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.,Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | | | - Edith Nakku-Joloba
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Juliet Kiguli
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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19
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Vaghela G, Hermoso C, Ahmadi A, Lucero-Prisno DE. Sex Workers Should Be Included in COVID-19 Vaccination Efforts. Am J Trop Med Hyg 2021; 105:1460-1462. [PMID: 34695788 PMCID: PMC8641315 DOI: 10.4269/ajtmh.21-0438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 10/10/2021] [Indexed: 11/21/2022] Open
Abstract
As the COVID-19 pandemic takes its toll on citizens across the globe, more people turn to sex work for survival. Because sex work is inherently physical and intimate, sex workers become defenseless against the virus and act as a bridge for transmitting the virus to their clients and society. Often, sex workers are the victims of violence and homelessness, and are devoid of health-care facilities, including HIV treatment, and are frequently exposed to a large number of individuals as dictated by the nature of their work. Their survival instincts would drive them to take part in their usual job to earn money, despite added health risks, to survive and feed their families. Worldwide, sex workers do not fully benefit from the COVID-19 responses, particularly in health, social, and economic aid assistance and services. Hence, it is essential to include this vulnerable population in the COVID-19 vaccination programs to halt the further spread of the virus.
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Affiliation(s)
| | | | - Attaullah Ahmadi
- Medical Research Center, Kateb University, Kabul, Afghanistan
- Department of Public Health, International School of Medicine, Bishkek, Kyrgyzstan
| | - Don Eliseo Lucero-Prisno
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Zenouzi A, Rezaei E, Behboodi Moghadam Z, Montazeri A, Maani S, Vasegh Rahimparvar SF. Reproductive Health Concerns of Women With High Risk Sexual Behaviors. SAGE Open Nurs 2021; 7:23779608211017779. [PMID: 34458577 PMCID: PMC8385587 DOI: 10.1177/23779608211017779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 04/23/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Expansion of reproductive health services and addressing its different aspects in national and international levels is an important step towards ensuring family and public health. Female sex workers are a vulnerable population that are exposed to high risk sexual behaviors and increased incidence of co-morbid health problems. This study aims to identify the concerns of women with high risk sexual behaviors. Clarifying different aspects of reproductive health and its problems in female sex workers can assist relevant authorities to plan and intervene on reproductive health and to provide more effective solutions on this issue. Methods A qualitative study was conducted using a conventional content analysis approach. Snowball sampling was performed in 20 volunteer women with high risk sexual behaviors through in-depth semi-structured interviews conducted in drop-in centers, triangle centers, etc. The data were analyzed through conventional content analysis using the MAXQDA software. Results Five main categories and 13 subcategories emerged during the interviews. The main categories included violence, fear, and lack of knowledge, stigma, and psychological problems. Women with high risk sexual behaviors have several reproductive health concerns, including unwanted pregnancy, abortion, STIs (Sexually transmitted infections), HIV, etc. In addition, different types of violence and threats against women, intimidation, objectification, stigma, unresponsiveness of counselling centers, patriarchal culture, gender inequality, etc. were observed in these women. Conclusion The study revealed that women in this study experienced deep problems of reproductive health and little attention is paid to them by authorities. Proper planning and appropriate solutions should be provided to solve the problems of these women and the society.
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Affiliation(s)
- Azade Zenouzi
- School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.,School of Nursing and Midwifery, Islamic Azad University, Pishva Branch, Tehran, Iran
| | - Elham Rezaei
- Reproductive Health Research Center, Clinical Research Institute, Urmia University of Medical Sciences, Urmia, Iran
| | | | - Ali Montazeri
- Health Metrics Research Center, Institute for Health Sciences Research, Academic Center for Education, Culture and Research, Tehran, Iran
| | - Sakineh Maani
- Department of Nursing and Midwifery, Islamic Azad University, Varamin-Pishva Branch, Tehran, Iran
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21
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Woensdregt L, Nencel L. Taking small steps: Sensitising the police through male sex workers' community-led advocacy in Nairobi, Kenya. Glob Public Health 2021; 17:2316-2328. [PMID: 34278970 DOI: 10.1080/17441692.2021.1954681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Kenyan sex worker-led organisations (SWLOs) often play a key role in the national HIV response. Accounts of these organisations frequently focus on their community-led approaches to promote sexual health. This paper addresses sensitisation, an underexplored but significant activity in the political agency of sex workers (SWs). Drawing on ethnographic fieldwork in a male SWLO in Nairobi, we examine how male SWs strategically use their position in the national HIV response to create spaces of police sensitisation. Taking police sensitisation as a manifestation of community-led advocacy and a 'politics of small steps', we examine how SWs respond to, resist and remake the political landscape of police violence. The strategy supports SWs in changing existing power relationships between themselves and the police, albeit within the confines of a criminalising legal system. The analysis of sensitisation practices supports a reimagining of SWLOs that stresses their political agency in the production of new political spaces and expands the focus on African SWLOs beyond HIV work to their political activities, which advance SWs' health, rights and social justice.
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Affiliation(s)
- Lise Woensdregt
- Department of Sociology, Vrije Universiteit, Amsterdam, The Netherlands
| | - Lorraine Nencel
- Department of Sociology, Vrije Universiteit, Amsterdam, The Netherlands
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22
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Keuroghlian AS, Mujugira A, Mayer KH. Healthcare worker training to improve quality of care for sexual and gender minority people in sub-Saharan Africa: learning from efforts in Uganda. J Int AIDS Soc 2021; 24 Suppl 3:e25728. [PMID: 34189872 PMCID: PMC8242968 DOI: 10.1002/jia2.25728] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/11/2021] [Accepted: 04/20/2021] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Training in care for sexual and gender minority (SGM) populations is critical for ending the HIV epidemic. SGM people, particularly men who have sex with men (MSM) and transgender women, experience disproportionate HIV infection across the globe. The objective of this commentary was to synthesize facilitators of and barriers to SGM health training efforts for healthcare workers in Uganda, in order to help inform potential priorities, strategies and next steps to advance culturally responsive HIV-related care for SGM communities across Uganda and sub-Saharan Africa. DISCUSSION SGM health training often includes education on: foundational concepts and language; stigma, discrimination and SGM health disparities; understanding and addressing implicit bias; sensitive and effective communication and building SGM-inclusive and welcoming healthcare environments. Clinicians' education includes sexual and gender histories, sex-positive HIV counselling, sexually transmitted infections, HIV pre-exposure prophylaxis and gender-affirming hormone therapy. SGM communities in sub-Saharan Africa have often experienced discrimination, persecution, incarceration and physical violence, and they encounter unique barriers to engagement in sexual health services and HIV prevention and treatment. SGM health training efforts in Uganda reveal challenges to and opportunities for advancing equity for SGM communities in sexual health and HIV medical care across the region. In Uganda, SGM community advocacy, as well as policies and programmes of the Ministry of Health and US President's Emergency Plan for AIDS Relief, have increased readiness and need for scaling up training and skills-sharing in SGM-focused HIV and sexual healthcare, including Ugandan-led and international initiatives. CONCLUSIONS Numerous challenges exist to widespread culturally responsive HIV and sexual healthcare for SGM communities in sub-Saharan Africa. Lessons learned from healthcare worker training efforts in Uganda may inform future replication, adaptation and dissemination initiatives to meet the needs of more SGM communities in the region. Evaluation of SGM health training programmes to determine the impact on HIV virological suppression and sexual health outcomes will be critical for identifying best practices and strategies that may support advancing HIV epidemic control for SGM communities in Uganda and across sub-Saharan Africa.
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Affiliation(s)
- Alex S Keuroghlian
- The Fenway InstituteFenway HealthBostonMAUSA
- Department of PsychiatryMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Andrew Mujugira
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Kenneth H Mayer
- The Fenway InstituteFenway HealthBostonMAUSA
- Department of MedicineBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMAUSA
- Department of Global Health and PopulationHarvard T.C. Chan School of Public HealthBostonMAUSA
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23
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Moyo I, Macherera M. The experiences of sex workers accessing HIV care services in Bulawayo, Zimbabwe. Afr Health Sci 2021; 21:593-602. [PMID: 34795712 PMCID: PMC8568253 DOI: 10.4314/ahs.v21i2.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although sub-Saharan African countries have rolled out massive HIV treatment and care programmes, there is little evidence of these having embraced key population groups particularly female sex workers. Due to the criminalisation of sex work in countries like Zimbabwe, research on HIV and its impact on this group is sparse. The absence of an enabling environment has hindered access to HIV care and treatment services for female sex workers. OBJECTIVES To gain an in-depth understanding of the experiences of female sex workers accessing HIV care and treatment services to enhance programming and planning for this key population group. METHODS This study was qualitative and phenomenological. Data saturation determined the sample size of 20 participants. Data was collected using in-depth interviews that were audio recorded, transcribed, and subjected to thematic content analysis. RESULTS Our findings demonstrate varying dynamics between the private and public sector HIV care services for sex workers, with facilitators and barriers to access to care. CONCLUSION Health workers need sensitization and training in the provision of differentiated care. For effective linkage to and retention in care an enabling environment is critical.
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Bielenberg J, Swisher G, Lembke A, Haug NA. A systematic review of stigma interventions for providers who treat patients with substance use disorders. J Subst Abuse Treat 2021; 131:108486. [PMID: 34217033 DOI: 10.1016/j.jsat.2021.108486] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 05/14/2021] [Accepted: 05/15/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Stigma surrounding substance use disorders (SUDs) is a frequently cited barrier to treatment engagement. Research consistently demonstrates that healthcare professionals' attitudes towards patients with addiction problems are often negative and may adversely impact service delivery. The current study presents a systematic review of stigma interventions for providers who treat patients with SUDs, in order to evaluate the quality of existing studies and potential for implementation in clinical settings. METHODS This systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases included PubMed, APA PsycInfo and the Cochrane Database of Systematic Reviews. Of the 1462 records identified between 2011 and 2019, 15 studies were eligible for inclusion. A narrative synthesis of stigma interventions summarized the change in stigmatizing attitudes held by providers. RESULTS Studies included heterogeneous and culturally diverse samples of providers (N = 1324), who varied by age, location, discipline, and experience, with the exception of primarily female providers (75%). Results delineated six types of provider stigma interventions with components including online education, in-person education, in-person contact with consumers in recovery, or some combination of these elements. The highest quality studies incorporated motivational interviewing or communication training interventions, and many interventions combined either in-person mentorship or contact with individuals in recovery. Positive effects on provider attitudes occurred at several levels of educational and consumer contact interventions. Interventions with consumer contact demonstrated long-term maintenance of attitudinal shifts. Despite significant methodological limitations and low-quality assessment ratings, several studies utilized real-world providers and patients, as well as practical, innovative, brief, and potentially cost-effective interventions, particularly in locations with limited technological resources. CONCLUSIONS Research on provider stigma interventions increased in recent years, indicating greater worldwide attention to the negative impact of stigma. While educational interventions alone can be helpful in attitudinal change, contact with individuals in recovery from SUDs is a vital component of provider stigma interventions, particularly for lasting effects. This review highlights the importance of including implementation outcomes, such as sustainability and cost-effectiveness, in the study of stigma interventions for providers of addiction treatment.
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Affiliation(s)
- Jennifer Bielenberg
- Department of Psychology, Palo Alto University, 1791 Arastradero Road, Palo Alto, CA 94304, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
| | - Gabrielle Swisher
- Department of Psychology, Palo Alto University, 1791 Arastradero Road, Palo Alto, CA 94304, USA.
| | - Anna Lembke
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
| | - Nancy A Haug
- Department of Psychology, Palo Alto University, 1791 Arastradero Road, Palo Alto, CA 94304, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
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25
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Mgopa LR, Rosser BRS, Ross MW, Lukumay GG, Mohammed I, Massae AF, Leshabari S, Mkonyi E, Mushy SE, Mwakawanga DL, Trent M, Wadley J, Bonilla ZE. Cultural and clinical challenges in sexual health care provision to men who have sex with men in Tanzania: a qualitative study of health professionals' experiences and health students' perspectives. BMC Public Health 2021; 21:676. [PMID: 33827508 PMCID: PMC8028207 DOI: 10.1186/s12889-021-10696-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/18/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Health care providers across sub-Saharan Africa continue to face challenges while delivering sexual health care services. We explored the experiences, views and challenges of health care professionals and health students across different disciplines in Tanzania, towards delivery of sexual health services to men who have sex with men. METHODS Utilizing a qualitative approach, we recruited 121 health care professionals (providers) and students from the fields of midwifery, nursing and medicine in Dar es Salaam, Tanzania. We conducted 18 focus groups discussions, stratified by profession and experience, to investigate clinical management and challenges while addressing a case of an adult male presenting with rectal gonorrhea. RESULTS Findings indicated this case as extremely sensitive, clinical management involved establishing rapport and consent, medical care from history taking to treatment, and referral to other specialties. However, the illegal status of homosexuality in Tanzania was a primary concern to participants, this triggered the clinical care of this case scenario as challenging. There were uncertainties whether or not that such a case should be reported to the authorities. CONCLUSION Findings from this study revealed a need for training health students in Tanzania to address sexual health issues including accurate information on homosexuality, reporting requirements and clinical management in the legal and socio-cultural context of the African continent.
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Affiliation(s)
- Lucy R Mgopa
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - B R Simon Rosser
- University of Minnesota, School of Public Health, 1300 S. 2nd St., Minneapolis, MN, 55454, USA.
| | - Michael W Ross
- University of Minnesota, School of Public Health, 1300 S. 2nd St., Minneapolis, MN, 55454, USA
| | - Gift Gadiel Lukumay
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Inari Mohammed
- University of Minnesota, School of Public Health, 1300 S. 2nd St., Minneapolis, MN, 55454, USA
| | - Agnes F Massae
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Sebalda Leshabari
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Ever Mkonyi
- University of Minnesota, School of Public Health, 1300 S. 2nd St., Minneapolis, MN, 55454, USA
| | | | - Dorkasi L Mwakawanga
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Maria Trent
- Johns Hopkins University, Washington, DC, USA
| | - James Wadley
- Lincoln University, Counseling and Human Services Department, 1570 Baltimore Pike, Philadelphia, PA, 19352, USA
| | - Zobeida E Bonilla
- University of Minnesota, School of Public Health, 1300 S. 2nd St., Minneapolis, MN, 55454, USA
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Restar A, Ogunbajo A, Adia A, Nazareno J, Hernandez L, Sandfort T, Lurie M, Cu-Uvin S, Operario D. Using structural equation modelling to characterise multilevel socioecological predictors and mediators of condom use among transgender women and cisgender men who have sex with men in the Philippines. BMJ Glob Health 2020; 5:e002463. [PMID: 32699154 PMCID: PMC7380848 DOI: 10.1136/bmjgh-2020-002463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Risks for condomless sex among transgender women and cisgender men who have sex with men (trans-WSM and cis-MSM, respectively) in the Philippines, where HIV recently became a national public health crisis, are shaped and exacerbated by various risk factors across multiple levels. METHODS Between June 2018 and August 2019, we conducted a cross-sectional online study with 318 trans-WSM and cis-MSM respondents from Manila and Cebu cities. Structural equational modelling procedures were performed to determine direct, indirect and overall effects between condom use and latent variables across multiple socioecological levels: personal (ie, condom self-efficacy), social (ie, social capital), environmental (ie, barriers to condom and HIV services) and structural (ie, structural violence, antidiscrimination policies). RESULTS Adjusted for gender, age, location and income, our model showed that: (1) all latent variables at the structural and environmental levels were significantly positively associated with each other (all ps<0.05); (2) barriers to condom and HIV services were significantly negatively associated with social capital (p<0.001) as well as condom self-efficacy (p<0.001); and (3) there were significantly positive associations between social capital and condom self-efficacy (p<0.001), and between condom self-efficacy and condom use (p<0.001). Moreover, social capital and condom self-efficacy fully mediated and buffered the negative effects between environmental and structural barriers and condom use. CONCLUSION This is the first known study pointing to multiple relationships and pathways across multiple socioecological levels that can potentially be leveraged for future interventions aimed at improving condom use among Filipinx trans-WSM and cis-MSM. Such interventions should be multicomponent and build and/or strengthen social capital and condom self-efficacy, as well as intentionally target prominent structural and environmental barriers to condom use.
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Affiliation(s)
- Arjee Restar
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
- The Philippine Health Initiative for Research, Service, and Training, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Adedotun Ogunbajo
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Alexander Adia
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
- The Philippine Health Initiative for Research, Service, and Training, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jennifer Nazareno
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
- The Philippine Health Initiative for Research, Service, and Training, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Laufred Hernandez
- Department of Behavioral Sciences, University of the Philippines Manila, Manila, Metro Manila, Philippines
| | - Theo Sandfort
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, New York, New York, USA
| | - Mark Lurie
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Susan Cu-Uvin
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
- The Philippine Health Initiative for Research, Service, and Training, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
- The Philippine Health Initiative for Research, Service, and Training, Brown University School of Public Health, Providence, Rhode Island, USA
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HIV-Related Implementation Research for Key Populations: Designing for Individuals, Evaluating Across Populations, and Integrating Context. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S206-S216. [PMID: 31764256 DOI: 10.1097/qai.0000000000002191] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Key populations, including men who have sex with men, transgender people, sex workers, people who inject drugs, and incarcerated populations, experience high burdens of HIV and urgently need effective interventions. Yet the evidence base for implementation research (IR) with key populations remains weak and poses specific challenges to epidemiologic inference. We apply the Consolidated Framework for IR to consider specific challenges and recommendations for IR with key populations. DISCUSSION Individuals within key populations exist within inner and outer settings-including organizational structures, legal (eg, criminalization), and funding environments-which influence the design, adoption and fidelity of interventions, and the potential sustainability of intervention scale-up. Underlying vulnerabilities and external stressors experienced at the individual level (eg, homelessness, violence) further impact participation and retention in IR. Thus, researchers should account for representation in the research process, beginning with community engagement in IR design and consideration of enumeration/sampling methods for key populations who lack probabilistic sampling frames. Interventions for key populations require substantial adaptation and complexity (eg, individually tailored, multicomponent) to ensure appropriateness; however, there is tension between the need for complexity and challenges to internal validity (fidelity) and external validity (generalizable scale-up). Finally, integrating contextual, sampling, and implementation elements into analytic approaches is critical for effectiveness evaluation. CONCLUSIONS Translation of efficacious findings at the individual level to effectiveness at the population level requires recognition of risk heterogeneity. Recognizing the nuances of working with key populations is essential to ensure that individuals are represented by design and therefore gains in population health can be achieved.
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Kutner BA, Wu Y, Balán IC, Meyers K. "Talking About it Publicly Made Me Feel Both Curious and Embarrassed": Acceptability, Feasibility, and Appropriateness of a Stigma-Mitigation Training to Increase Health Worker Comfort Discussing Anal Sexuality in HIV Services. AIDS Behav 2020; 24:1951-1965. [PMID: 31858301 DOI: 10.1007/s10461-019-02758-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Health workers report challenges to broaching sexual behavior with gay and bisexual men (MSM). We conducted a stigma-mitigation training to increase provider-initiated conversation about anal sexuality among Chinese health workers. The two-day workshop, titled Smarter Sex is the New Safer Sex: Anal Pleasure and Health, coupled information about anal physiology and sexual response with gradual exposure to trainees' emotional and cognitive responses. We analyzed surveys and one-time interviews. Acceptability (satisfaction with training activities and recommended practices), feasibility (compatibility with participants' current practices), and appropriateness (perceived fit with participants' work mission and goals) were high, reaching 84-95% of the scale range, though with variable ratings for trainee comfort during participation. Qualitative data confirm health workers' motivation to discuss anal sexuality and the value of learning about anal physiology and sexual response, but revealed continued uncertainty about how to broach and navigate discussion with clients. Refinement of the training to align with health worker recommendations and to augment communication options and skills is warranted, as is involvement of MSM clientele themselves.
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Affiliation(s)
- Bryan A Kutner
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, USA
| | - Yumeng Wu
- Aaron Diamond AIDS Research Center, The Rockefeller University, New York, USA
| | - Ivan C Balán
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, USA
| | - Kathrine Meyers
- Aaron Diamond AIDS Research Center, The Rockefeller University, New York, USA.
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Gruchy TD, Vearey J. "Left behind": why implementing migration-aware responses to HIV for migrant farm workers is a priority for South Africa. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2020; 19:57-68. [PMID: 32153239 DOI: 10.2989/16085906.2019.1698624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Like many other countries, South Africa (SA) has committed to the Sustainable Development Goals that aim to "leave no-one behind", in efforts towards universal health coverage, and meeting the UNAIDS 90-90-90 targets through the implementation of universal test and treat (UTT) interventions. SA is associated with high levels of international and internal migration that, in certain contexts, are known to (1) increase the risk of acquiring HIV and (2) present challenges to HIV treatment access and continuity. Despite this, migration and mobility are not adequately considered in responses to HIV. As SA rolls out UTT programmes and antiretroviral treatment as prevention (TasP) interventions, including pre-exposure prophylaxis (PreP), there is an urgent need to ensure that these are migration-aware and mobility-competent. In SA, a key population that experiences a disproportionate HIV burden is international migrant farm workers living and working on commercial farms along the border with Zimbabwe. In this article, a social determinants of health approach is applied to explore the context within which this population struggles to access positive determinants of health, including the public health care system, and the implications of this for HIV programming. It is argued that, unless policies and programming become migration-aware and mobility-competent, UTT and TasP interventions will struggle to address the high burden of HIV among this population and, as a result, progress towards global health targets will be limited.
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Affiliation(s)
- Thea de Gruchy
- The African Centre for Migration & Society, University of the Witwatersrand, Johannesburg, South Africa
| | - Jo Vearey
- The African Centre for Migration & Society, University of the Witwatersrand, Johannesburg, South Africa
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