Discriminatory attitudes towards people living with HIV among health facility staff
Export Indicator
Progress towards reducing negative attitudes towards people living with HIV among health facility staff.
An individual driver of HIV stigma and discrimination in health-care settings is attitudes and opinions of health facility staff towards people living with HIV. Measuring stereotypes and prejudices among health facility staff towards people living with HIV is important. Values and attitudes may affect whether a provider treats clients with dignity; may affect the health-care options offered to people, for example which people are offered testing, and when and how people are offered testing; and may lead to inaccurate risk assessment.
Number of health facility staff who agree with any of the first three statements and/or disagree with the fourth statement.
Number of all health facility staff who answered at least one statement.
Numerator/denominator.
Any type of facility-based survey, such as the Service Provision Assessment, quality assurance surveys, or the Health Policy Project Measuring HIV Stigma and Discrimination among Workers in Health Facilities Questionnaire. The indicator is constructed from responses to the following question:
Do you strongly agree, agree, disagree or strongly disagree with the following statements?
A. Most people living with HIV do not care if they infect other people.
B. People living with HIV should feel ashamed of themselves.
C. People get infected with HIV because they engage in irresponsible behaviours.
D. Women living with HIV should be allowed to have babies if they wish.
The numerator includes respondents who agree or strongly agree with any of statements A–C and/or disagree or strongly disagree with statement D.
The questions recommended for the construction of this indicator were selected from a longer, 25-item tool that has been validated in health-care settings in several countries. (Measuring HIV stigma and discrimination among health facility staff. Washington, DC: Futures Group, Health Policy Project; 2013 (http://www.healthpolicyproject.com/index.cfm?ID=publications&get=pubID&p...).
This indicator directly assesses discriminatory attitudes towards people living with HIV among health facility staff, which has been linked with poorer engagement in care and poorer adherence to treatment among people living with HIV. Each item included in this indicator captures an important aspect of stigma that can be shifted or improved through intervention:
“Most people living with HIV do not care if they infect other people” aims to capture the level of blame from staff associated with “spreading” HIV in the community.
“People get infected with HIV because they engage in irresponsible behaviours” is related to the perception of a person’s responsibility for their infection. It captures the assumption that people are to blame for contracting HIV or contracted HIV because they were irresponsible with their health. Identifying this perception among providers is important. Based on assumptions about a person’s responsibility or ability to adhere to treatment, this perception can influence clinical decisions, and lead providers to not offer the preferred course of treatment.
“People living with HIV should feel ashamed of themselves” taps into an emotional component of stigma.
“Women living with HIV should be allowed to have babies” is aimed at assessing views on the reproductive rights of women living with HIV.
This indicator can be subject to social desirability bias, which occurs when respondents provide what they perceive to be the “correct” or “acceptable” response rather than what they actually believe, leading to underreporting of stigma. Even with the potential for this type of response bias, field-testing showed high levels of stigmatizing attitudes across these four statements and across countries. This suggests the observed stigma levels would be even higher in the absence of response bias. The use of self-administered rather than interviewer-administered questionnaires may reduce social desirability bias by providing a greater sense of anonymity.
Research has shown that respondents who skip these types of question, including due to discomfort with the question, will answer at least one question if several questions measuring the same stigma domain are provided. By offering four questions, if a respondent has a stigmatizing response to at least one of the items, the respondent is included in the numerator and denominator. Using a range of questions helps to reduce missing data and social desirability on this indicator.
Carr D, Kidd R, Fitzgerald M, Nyblade L. Achieving a stigma-free health facility and HIV services: resources for administrators. Washington, DC: Futures Group, Health Policy Project; 2015 (https://www.healthpolicyproject.com/pubs/281_SDAdministratorsGuide.pdf, accessed 7 November 2023).
Measuring HIV stigma and discrimination among health facility staff. Washington, DC: Futures Group, Health Policy Project; 2013 (http://www.healthpolicyproject.com/index.cfm?ID=publications&get=pubID&p..., accessed 16 November 2013).
Krishnaratne S, Bond V, Stangl A, Pliakas T, Mathema H, Lilleston P, et al. Stigma and judgment towards people living with HIV and key population groups among three cadres of health workers in South Africa and Zambia: analysis of data from the HPTN 071 (PopART) Trial. AIDS Patient Care STDs. 2020;34(1):38–50.
Sampling manual for facility surveys for population, maternal health, child health and STD programs in developing countries. Chapel Hill, NC: MEASURE Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill; 2001 (https://www.measureevaluation.org/resources/publications/ms-01-03.html, accessed 7 November 2023).
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Stangl A, Lilleston P, Mathema H, Pliakas T, Krishnaratne S, Sievwright K, et al. Development of parallel measures among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc. 2019;22(12):e25421.