Principals, Approaches

and Tools for

Stigma-Reduction in
Health Facilities
Laura Nyblade, PhD

Senior Technical Advis or , Stigma & Discrimination

Health Policy Project and RTI

Presentation Guide
Background
Why
Definitions & Conceptualization
Forms & consequences

Overview of general stigma-reduction

program strategies
Examples of how they have been
applied in health care settings
Tools & Resources

. If we do not appreciate
the nature
and impact of stigma, none
of our interventions can
begin to be successful.
Edward Cameron, Constitutional
Court Justice in South Africa

Why?
Powerful social process that:
Turns difference into inequity &
disadvantage
Maintains/upholds inequitable structures
Leads to social & economic exclusion
Fuels and can be used to justify violations of
human rights, discriminatory policies & laws
Intensifies & sustains vulnerability
Impedes access to health & other services

Stigma impedes programmatic efforts

Prevention
Testing
Disclosure
Risk Recognition
Treatment

Treatment

Access
Timely uptake
Adherence
Delivery/Quality of Care
Human Capital
Health care providers
receiving care
Secondary S&D

Forms-Impact on Peoples Lives

Physical and social isolation
Loss of relationships
Gossip & Verbal Abuse
Loss of livelihood
Loss of housing
Rejection by peers
Loss of reputation
Violence
Denial or sub-standard health care
Internalized stigma

Forms-Health Providers

Stigma Indicators Working Group, Tanzania, 2005

Neglect
Had to wait longer
Not having bed pans
changed
Receiving less
care/attention

Differential treatment
HIV test required before
care was given
HIV test required before
scheduling surgery
Using gloves for noninvasive exams
Extra precautions in
sterilizing instruments

Denied care
Denied treatment
Referral to another
provider/facility
Senior provider pushed client to
a junior provider
Junior provider pushed client to a
senior provider
Lack of consent
HIV testing without consent
Disclosing HIV status to
family without clients
consent

Verbal stigma

Gossip about a clients HIV

status

Scolding or blaming a client

 I overheard two nurses talking about

me. that I am HIV positive. After having

the baby, they put me in a separate room, no
one came to look after me.
When I went home, family members
refused to let me stay there. I had to rent
my own room and stay alone with my baby
and no one from the family came to see me.
.As soon as our customers learned that we
are HIV positive, they stopped coming and
our business collapsed.
Shared in an ISDS/ICRW stigma -reduction workshop,
2002

Definitions and
Conceptualization

Stigma-Goffman, 1963
An attribute that is deeply discrediting [and that
reduces the bearer] from a whole and usual
person to a tainted, discounted one.
By regarding others negatively, an individual
or group confirms their own normalcy and
legitimizes their devaluation of the other.
Disqualification from full social acceptance

Social Process (Link & Phelan, 2001)

Distinguish & label

differences
Associate negative attributes
to perceived differences
Separation of us from them
Status loss & discrimination

Discrimination
Unfair and unjust treatment of an
individual based on the basis of
the:
real or perceived status or attribute
(e.g. medical condition)
belonging, or being perceived to
belong, to a particular group (UNAIDS)

Cycle of Stigmatization
Marker

Greater susceptibility and

vulnerability to HIV & AIDS

Discrimination
Adapted from Sartorius, N., 2006.

Loading

Stigma

What works to reduce

HIV Stigma and
Discrimination

Successful programs
Put stigmatized groups at the core

Target a range of groups; Create alliances &

form new partnerships for influence and
expanded reach
Foster interaction between groups experiencing stigma
& those perpetrating it. Contact strategies
Model desirable behavior, hold up & reward role
models

Employ a combination of approaches, while

targeting a range of groups
Address immediately actionable drivers

Create Understanding:

Close the Intention-Action Gap

Foster understanding and
motivation for stigma
reduction by creating:
Recognition of stigma
The benefits of reducing it
Safe space to reflect and
gain skills for change

Address HIV Transmission

Fears & Misconceptions
How it is and is not transmitted
In-depth information
Interactively: Allow for
Yes I know that, but why?
Listen, learn & respond to specific
fears related to daily living & work
context

Discuss and Challenge the

Taboo
Provide safe spaces to discuss,
reflect, understand and question:
The values and beliefs that underlie
stigma and discrimination
Where they come from
What they do

Address the multiple intersecting &

associated stigmas of HIV
Sex workers, men who have sex with
men, drug users

Immediately Actionable Causes

Lack

of awareness
Fear of casual contact
Linking HIV with socially improper behavior

Individual

Environmental

Structural

Address attitudes
and behaviors

Meet needs for information,

training, and supplies

Policies, laws, and

institutions

Stigma &
DiscriminationReduction program in
Health Services
Some examples

Building institutional Support for

change in Vietnam (Horizons/ISDS/ICRW)
Relationship building with hospital authorities
Conducted & shared Baseline Research Results
Trained all cadres on:
Fear Driven Stigma: HIV transmission and
universal precautions
Socially Driven Stigma (blame & shame)
Tools Development: Checklist, toolkit
Participatory development of hospital policies
Improvements in structural environment
E.g. hand-washing facilities, sharps containers

Training
4 half-days
day basic HIV knowledge
1 day on Universal Precautions
day on social stigma co-facilitated by
PLHIV
Naming stigma through pictures
What is the meaning of stigma
Naming stigma in hospitals
Forms, Causes, Consequences
How it feels to be stigmatized

Joint development of Safe

and Friendly hospital policies
Each trained group developed their own
policy & presented it in plenary to hospital
Steering committee took all comments &
combined for final hospital policy
Access to services by PLHIV
HIV counseling and testing
Confidentiality
Universal Precautions
Training on HIV and AIDS
Dissemination of policy

Posters of policy posted throughout hospitals

Hospitals showed improvements

Significant declines in the
labeling of patients files
and beds with their HIV
status.
Better hospital-wide
implementation of
universal precautions.
Significantly improved mean scores on
fear-based and value-based stigma
indices among HWs .

Building institutional Support

for change
Partnering with hospitals as partners
not critics
Participatory approaches; evidence
of need/problem
Involving all categories of hospital
staff
Inclusion of people living with HIV as
co-facilitators
Development of practical tools

Creating partnerships &

reducing distance
between health care
providers and
stigmatized clients

Reducing Stigma & Discrimination

Towards Sex Workers
Ashodaya-Samithi, Mysore,
India

Trained Peer Patient

advocates placed in
Public Hospitals
Sex workers found
easier to access services
Opportunity for
increased contact and
understanding

Swathi Mahila Sangha &

partners, Bangalore, India

Ensuring Dignity and

Rights among Sex
Workers in Bangalore
Rose Campaign
Hold up & reward
positive behavior
Opened space for
dialogue

Resources

General Tools
Challenging & Addressing
Stigma towards

People living with HIV

Men who have sex with men
Sex workers
Drug users

Guidance Documents

Health Care Specific

Safe & Friendly Health Facility
Trainers Guide
(ISDS/ICRW/Horizons tools, Vietnam)

Reducing Stigma and

Discrimination Related to HIV
and AIDS: Training for Health
Care Workers (Engender Health)
Reducing HIV Stigma &
Gender Based Violence:
Toolkit for Health Care
Providers in India
(ICRW/BPWT/Levi Strauss Foundation)

Global Stigma-Reduction
toolkit for health care settings
(Draft)

Stigma Action Network

Working for a World Free of
HIV-related Stigma
www.stigmaactionnetwork.org

SAN Mission & Goals

To reduce HIVrelated stigma and
discrimination
through a dynamic
network that will
catalyze action and
commitment locally,
regionally and
globally through
knowledge sharing,
dialogue and
partnerships

1. Bring together diverse

stakeholders to share
experiences, best practices,
knowledge, tools, and research
around HIV-related stigma and
discrimination.
2. Facilitate innovative solutions
and expand the reach of best
and promising practices to
reduce HIV-related stigma and
discrimination.
3. Promote research across
disciplines to expand the
evidence base for HIV-related
stigma and discrimination
reduction efforts

How can you participate?

Join the network:

Go to www.stigmaactionnetwork.org
Click on the Join Us link in the top right-hand corner and
register
Log-in to the site and create your member profile and
organization profile

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Forthcoming in August, 2011

Hue Now
Public & media
figure- a national
inspiration
Time magazine
Asia hero, 2004
Hoa Phuong
(Flamboyant Flower)

Time Asia

Being involved in various activities of ISDS I felt great relief I no longer wanted to hide
my positive status. The disclosure helped me to overcome self-stigma and it was a
magic medicine that made me confident and strong.

Thank You!
www.healthpolicyproject.com

The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International
Development (USAID) under Cooperative Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is
implemented by Futures Group, the Centre for Development and Population Activities (CEDPA), Futures Institute,
Partners in Population and Development Africa Regional Office (PPD ARO), Population Reference Bureau (PRB),
Research Triangle Institute (RTI) International, and the White Ribbon Alliance for Safe Motherhood (WRA)