Li L, Wu Z, Liang LJ, Lin C, Guan J, Jia M, Rou K, Yan Z. Reducing HIV-related stigma in health care settings: A randomized controlled trial in China. Am J Public Health. 2013 Feb;103(2):286-92. doi: 10.2105/AJPH.2012.300854.
To reduce health care service providers' stigmatizing attitudes and behaviors and to increase their comfort levels when working with people living with HIV (PLWH) in primary health care settings.
Forty county-level hospitals in two provinces of China (Fujian and Yunnan).
Randomized controlled trial.
Physicians, nurses and laboratory technicians having regular contact with patients (regardless of patients' HIV status).
Reduction in prejudicial attitude, reduction in avoidance intent, increase in institutional support.
Hospitals were selected using a random number table. Within each province, hospitals were pair-matched by type of facility, i.e. whether general or specialized; size of hospital, i.e. the number of beds and number of staff; and HIV-related services, i.e. the number of HIV cases, whether antiretroviral therapy (ART) is provided, and history of occupational exposure. After baseline assessment, investigators randomized each pair of hospitals to the "White Coat, Warm Heart" intervention condition or to the control condition. Provider participants from each hospital were selected from staff rosters using systematic random sampling. The sample ratios of doctors, nurses, and laboratory technicians were pre-set at 50%, 45%, and 5%, respectively, to reflect the ratio of these staff categories at the county hospitals.
The intervention was implemented by health educators from provincial and district disease control centers. In each province, facilitators received extensive training on research ethics, facilitator role, intervention principles and delivery, session-by-session content flow, and the protocol for emergency situations. In each intervention hospital, investigators identified three popular opinion leaders (POLs). POLs attended four group sessions over a one-month period and three follow-up "reunion" sessions after the initial training. The four sessions covered 1) complying with universal precaution procedures and ensuring occupational safety; 2) fighting against stigma and improving the provider-patient relationship; 3) taking actions and making efforts to care for patients; and 4) overcoming difficulties and "building up a better medical environment." The intervention incorporated group discussion, games, and role-play to encourage full participation of trainees. Trained POL providers served as behavior-change endorsers and disseminated intervention messages to their co-workers.
Intervention messages were pre-designed and consistent across hospitals. Interactive techniques were used to help POLs practice and refine their skills to effectively deliver the messages to other providers. POLs established goals for engaging in informal conversations with co-workers between weekly sessions. The target audience could be any service providers in the hospitals, not necessarily those who participated in the study. Conversational outcomes were reviewed and discussed at subsequent sessions. Reunion activities focused on group solidarity, problem solving, and skill building through a new set of interactive games and activities to reinforce POLs' continued efforts. Intervention outcomes were evaluated at baseline and at six- and 12-month follow-up assessments. At baseline and at each assessment, all participating providers independently completed questionnaires, with a trained interviewer available to answer questions. Participants were compensated 50 yuan (USD $7.70) for each assessment.
Prejudicial attitudes toward PLWH were measured with an adapted version of a United States Agency for International Development (USAID) instrument for assessing stigma,(1) using a Likert scale with values ranging from "strongly agree" to "strongly disagree." Examples of statements used in the instrument include "People who got HIV/AIDS through sex or drug use got what they deserved" and "AIDS is a punishment for bad behavior." The instrument was pilot-tested in the investigators' pilot study to ensure cultural relevancy.(2) To measure avoidance intent, investigators adapted an instrument used in a study at the University of California, Davis.(3) Participants were presented with eight hypothetical situations involving potential contact with PLWH. A similar Likert scale was used as in the measurement of prejudicial attitudes. This instrument was also previously pilot-tested.(2) The third outcome measured was support from participants' institutions, including the availability of support related to infection protection and HIV care in their hospitals, including universal precaution supplies, postexposure prophylaxis materials and procedures and accessibility of HIV information and training. Investigators calculated this measure by summing "yes" responses to questions about each aspect, with a higher number indicating better perceived institutional support in the hospital.
Twenty (24%) of 85 hospitals in Fujian province and 20 (16%) of 129 hospitals in Yunnan province were selected for inclusion in the trial. With informed consent, investigators recruited and trained 20 to 25 POLs from each of the 20 intervention hospitals, yielding a total of 456 POLs. Forty-four service providers were randomly sampled from each of the 40 hospitals, resulting in a total of 1760 provider participants.
At baseline, 18 (45%) clinics had 200 or fewer hospital beds, and three had more than 500 hospital beds; 17 clinics reported no HIV cases, and seven reported at least 10 HIV cases. More than 65% of the service providers were women, and the average age of providers was about 38 years. Of providers, 48% in the control group and 50% in the intervention group were physicians. More than 55% of the service providers had prior contact with PLWH. Investigators observed no significant differences for clinic- and provider-level characteristics at baseline. They also observed comparable levels of prejudicial attitude, avoidance intent, and institutional support in each group.
Compared with the control group, the invention group showed a significantly higher reduction in prejudicial attitude at six months (mean difference [MD]= -2.40, standard error [SE]=0.22; p<.001). This difference increased at the 12-month follow-up (MD= -3.77, SE=0.27; p<.001) after controlling for age, gender, occupation, prior contacts with PLWH, province, number of hospital beds, and number of HIV cases reported. Prejudicial attitude was associated with providers who had no prior contacts with PLWH (p=.001), province (p=.007), and more HIV cases reported (p=.003). The intervention group showed a significantly higher reduction in avoidance intent (MD= -1.10; SE=0.17; p<.001) and a significantly higher increase in institutional support (MD=0.39; SE=0.13; p<.003) at 6 months after controlling for the same set of selected covariates. The intervention effects on avoidance intent and institutional support were sustained and strengthened at 12 months (MD= -1.86, SE=0.21; p<.001 and MD=0.82, SE=0.16; p<.001, respectively). Providers' prior contact with PLWH was also associated with lower avoidance intent (p<.001) and higher institutional support (p=.011).
The authors conclude that a reduction in stigmatizing attitudes and behaviors could be achieved among health care providers with an intervention implemented in health care settings.
The overall risk of bias in this trial is moderate. A random number table was used to select hospitals, and systematic random sampling was used to select participants, but the process is not further described. Allocation was not concealed. The trial was not blinded. There is also a risk of social desirability bias in the self-reported outcomes. However, there was virtually no loss to follow-up and apart from there being no data in the paper concerning patient experience of stigma reduction, the trial compares favorably to its registration documents.(4)
Since the early days of the epidemic, stigma and discrimination have been obstacles in the response to HIV. HIV-associated stigma is part of a complex social process that reinforces pre-existing stigma and discrimination associated with sexuality, race, injection drug use and other kinds of "outsider" status markers. HIV stigma can be part of the cultural fabric anywhere, but in health care providers it can have especially serious implications.(5, 6)
Although cultural contexts, baseline attitudes, resource availability and other factors will vary widely, hospitals in other settings may wish to consider implementing pilot programs using this intervention, adapting them as may be needed.
- United States Agency for International Development (USAID) Inter-Agency Working Group on Stigma and Discrimination. HIV-Related Stigma and Discrimination Indicators Development Workshop Report (2004).
- Li L, Liang LJ, Wu Z, Lin C, Wen Y. Individual attitudes and perceived social norms: reports on HIV/ AIDS-related stigma among service providers in China. Int J Psychol. 2009;44(6):443-450
- Herek GM. AIDS and stigma: 1999 survey items. (accessed 7 February 2013).
- ClinicalTrials.gov. POL and access intervention to reduce HIV stigma among service providers in China. Registration number NCT01052415. (accessed 7 February 2013)
- Kinsler JJ, Wong MD, Sayles JN, Davis C, Cunningham WE: The effect of perceived stigma from a healthcare provider on access to care amongst a low-income HIV positive population. AIDS Patient Care STDs 2007, 21(8):584-592
- Feyissa GT, Abebe L, Girma E, Woldie M. Stigma and discrimination against people living with HIV by healthcare providers, Southwest Ethiopia. BMC Public Health 2012, 12:522