Results from a difference‐in‐differences evaluation of health facility HIV and key population stigma‐reduction interventions in Ghana

Abstract

Introduction: Stigma undermines all aspects of a comprehensive HIV response, as reflected in recent global initiatives for stigma-reduction. Yet a commensurate response to systematically tackle stigma within country responses has not yet occurred, which may be due to the lack of sufficient evidence documenting evaluated stigma-reduction interventions. With stigma present in all life spheres, health facilities offer a logical starting point for developing and expanding stigma reduction interventions. This study evaluates the impact of a "total facility" stigma-reduction intervention on the drivers and manifestations of stigma and discrimination among health facility staff in Ghana. Methods: We evaluated the impact of a total facility stigma-reduction intervention by comparing five intervention to five comparable non-intervention health facilities in Ghana. Interventions began in September 2017. Data collection was in June 2017 and April 2018. The primary outcomes were composite indicators for three stigma drivers, self-reported stigmatizing avoidance behaviour, and observed discrimination. The principal intervention variable was whether the respondent worked at an intervention or comparison facility. We estimated intervention effects as differences-in-differences in each outcome, further adjusted using inverse probability of treatment weighting (IPTW). Results: We observed favourable intervention effects for all outcome domains except for stigmatizing attitudes. Preferring not to provide services to people living with HIV (PLHIV) or a key population member improved 11.1% more in intervention than comparison facility respondents (95% CI 3.2 to 19.0). Other significant improvements included knowledge of policies to protect against discrimination (difference-in-differences = 20.4%; 95% CI 12.7 to 28.0); belief that discrimination would be punished (11.2%; 95% CI 0.2 to 22.3); and knowledge of and belief in the adequacy of infection control policies (17.6%; 95% CI 8.3 to 26.9). Reported observation of stigma and discrimination incidents fell by 7.4 percentage points more among intervention than comparison facility respondents, though only marginally significant in the IPTW-adjusted model (p = 0.06). Respondents at intervention facilities were 19.0% (95% CI 12.2 to 25.8) more likely to report that staff behaviour towards PLHIV had improved over the last year than those at comparison facilities. Conclusions: These results provide a foundation for scaling up health facility stigma-reduction within national HIV responses, though they should be accompanied by rigorous implementation science to ensure ongoing learning and adaptation for maximum effectiveness and long-term impact.

Multi-level intersectional stigma reduction intervention to increase HIV testing among men who have sex with men in Ghana: Protocol for a cluster randomized controlled trial

“…In addition, champion groups emerging from the training at each facility developed and implemented additional stigma-reduction interventions. The HP+ Ghana pilot evaluation study trained 1,228 HCF staff of all levels (clinical/non-clinical) in five facilities over a span of 4 months, averaging 79% coverage of staff across facilities [ 47 ]. This was possible because of the approach, which trained health facility staff and clients living with HIV or from other stigmatized groups (e.g., MSM, sex workers) from each of the intervention facilities to deliver the two-day participatory stigma-reduction training in their facilities.…”

Impact of the Liberian National Community Health Assistant Program on Childhood Illness Treatment in Grand Bassa County, Liberia: A Difference-in-Differences Analysis of Population-Based Data

“…We assessed balance using standard IPTW diagnostics (see supplement 1) and then fit an IPT-weighted linear probability model that otherwise had the same form as the unadjusted analysis. (12,19–21)…”

“…We assessed balance using standard IPTW diagnostics (see supplement 1) and then fit an IPT-weighted linear probability model that otherwise had the same form as the unadjusted analysis. (12,(19)(20)(21) We assessed changes in provider types using survey design-adjusted tests for differences in proportions.…”

The PrEPARE Pretoria Project: protocol for a cluster-randomized factorial-design trial to prevent HIV with PrEP among adolescent girls and young women in Tshwane, South Africa

“…The Health Policy Project (HPP) Health Facility HIV-Stigma and Discrimination reduction training curriculum addresses barriers that arise from S&D. The HPP curriculum is based on a decade of implementation experience in Africa, South and South-East Asia, and the Caribbean [41]. It has been further adapted and implemented in a range of settings, most recently in Ghana [42], Tanzania [43,44] and other regions of the world [45,46]. The curriculum provides participatory training modules that address three key actionable drivers of HIV stigma: lack of understanding of S&D; fear of workplace HIV transmission; and clinic staff attitudes.…”

“…This includes building awareness of AGYW stigma-its causes, forms and manifestations-reflecting on one's own stigmatizing experiences and attitudes towards AGYW and developing a plan/pledge with actionable steps to reduce S&D in the clinic. The HPP curriculum [41,42] has been adapted with respect to time, target audience, and type of stigma relevant to this study. Modifications include examples of AGYW seeking services in pictorial displays and other pictures to elicit conversation in the workshops to address various types of bias (see Table 1 for an overview of the S&D reduction training).…”